The spatial politics of place and health policy: Exploring Sustainability and Transformation Plans in the English NHS

Navigating the micro-politics of major system change: The implementation of Sustainability Transformation Partnerships in the English health and care system

OBJECTIVE

To investigate how health and care leaders navigate the micro-politics of major system change (MSC) as manifest in the formulation and implementation of Sustainability and Transformation Partnerships (STPs) in the English National Health Service (NHS).

METHODS

A comparative qualitative case study of three STPs carried out between 2018-2021. Data collection comprised 72 semi-structured interviews with STP leaders and stakeholders; 49h of observations of STP executive meetings, management teams and thematic committees, and documentary sources. Interpretative analysis involved developing individual and cross case reports to understand the 'disagreements, 'people and interests' and the 'skills, behaviours and practice'.

FINDINGS

Three linked political fault-lines underpinned the micro-politics of formulating and implementing STPs: differences in meaning and value, perceptions of winners and losers, and structural differences in power and influence. In managing these issues, STP leaders engaged in a range of complementary strategies to understand and reconcile meanings, appraise and manage risks and benefits, and to redress longstanding power imbalances, as well as those related to their own ambiguous position.

CONCLUSION

Given the lack of formal authority and breadth of system change, navigating the micro-politics of MSC requires political skills in listening and engagement, strategic appraisal of the political landscape and effective negotiation and consensus-building.

What can clinical leaders contribute to the governance of integrated care systems?

BACKGROUND

Integrated care systems present enduring governance challenges associated with fostering interorganisational collaboration.

AIM

To understand how clinical leaders can make a distinct contribution to the governance and system leadership of integrated care systems.

METHODS

A qualitative interview study carried out between 2018 and 2019 with 24 clinical leaders, and a further 47 non-clinical leaders, involved in the governance of three Sustainability and Transformation Partnership in the English National Health Service.

RESULTS

Clinical leaders were found to make four distinct contributions: (1) making analytical insights into integration strategies that ensured their relevance and quality to clinical communities; (2) representing the views of clinicians in system decision-making thereby enhancing the legitimacy of change; (3) translation and communication activities to articulate integration strategies in favourable ways and ensure clinical engagement; and (4) relational work in the form of brokering and building connections and mediating conflict between multiple stakeholders. These activities varied across the levels of system governance and at different stages in the processes of change.

CONCLUSIONS

Clinical leaders can make a distinct contribution to the governance and leadership of integrated care systems based on their clinical expertise, membership professional networks, reputation and formal authority.

Developing architecture of system management in the English NHS: evidence from a qualitative study of three Integrated Care Systems

OBJECTIVE

Integrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving its goals by investigating how ICSs were developing, how system partners were balancing organisational and system responsibilities, how partners could be held to account and how local priorities were being reconciled with ICS priorities.

DESIGN

We carried out detailed case studies in three ICSs, each consisting of a system and its partners, using interviews, documentary analysis and meeting observations.

SETTING/PARTICIPANTS

We conducted 64 in-depth, semistructured interviews with director-level representatives of ICS partners and observed eight meetings (three in case study 1, three in case study 2 and two in case study 3).

RESULTS

Collaborative working was welcomed by system members. The agreement of local governance arrangements was ongoing and challenging. System members found it difficult to balance system and individual responsibilities, with concerns that system priorities could run counter to organisational interests. Conflicts of interest were seen as inherent, but the benefits of collaborative decision-making were perceived to outweigh risks. There were multiple examples of work being carried out across systems and 'places' to share resources, change resource allocation and improve partnership working. Some interviewees reported reticence addressing difficult issues collaboratively, and that organisations' statutory accountabilities were allowing a 'retreat' from the confrontation of difficult issues facing systems, such as agreeing action to achieve financial sustainability.

CONCLUSIONS

There remain significant challenges regarding agreeing governance, accountability and decision-making arrangements which are particularly important due to the recent Health and Care Act 2022 which gave ICSs allocative functions for the majority of health resources for local populations. An arbiter who is independent of the ICS may be required to resolve disputes, along with increased support for shaping governance arrangements.

Putting sheep scab in its place: A more relational approach

Since the reintroduction of sheep scab within the UK, its prevalence has increased despite several industry-led initiatives to control and manage the disease. Some studies have suggested that initiatives or policies should instead focus on specific places, such as geographically high-risk areas for sheep scab, which could allow for a more targeted approach. However, this risk of sheep scab has been measured in set geographical areas, without the reference to the interplay of topography, host, pathogen and the way in which humans socially and culturally define risk and place, potentially limiting the effectiveness of preventative initiatives. Therefore, the aim of the current study was to understand how place influences sheep farmers' approaches to the identification and management of the risk of sheep scab in their flocks. Qualitative data was collected from 43 semi-structured interviews with sheep farmers from England, Scotland, and Wales and was analysed by using the constant comparative approach. The codes were grouped into four concepts that influenced farmers' decision-making strategies for sheep scab control: perception of place; risk identification; risk categorisation; and risk management. These concepts were used as an analytical framework to identify three different 'places': 'uncontrollable places', 'liminal places' and 'protective places'. Each place reflects a different sheep scab control strategy used by farmers and shaped by their perceptions of place and risk. The 'uncontrollable places' category represented farmers who were located in areas that were geographically high-risk for sheep scab and who experienced a high frequency of sheep scab infestations in their flocks. The risk posed by their local landscape and neighbouring farmers, who neglected to engage in preventative behaviours, led them to feel unable to engage in effective risk management. Thus, they viewed scab as uncontrollable. The farmers within the 'liminal places' category were characterised as farmers who were located in high-risk areas for sheep scab, but experienced low levels of sheep scab infestations. These farmers characterised the risks associated with sheep scab management in terms of needing to protect their reputation and felt more responsibility for controlling sheep scab, which influenced them to engage in more protective measures. The farmers within the 'protective places' category were characterised as farming within low-risk areas and thus experienced a low level of sheep scab infestations. These farmers also described their risk in terms of their reputation and the responsibility they held for protecting others. However, they sought to rely on their low geographical risk of sheep scab as a main source of protection and therefore did not always engage in protective measures. These results suggest that place-based effects have significant impacts on sheep farmers' beliefs and behaviours and thus should be considered by policymakers when developing future strategies for sheep scab control.

NICE rapid guidelines: exploring political influence on guidelines

The National Institute for Health and Care Excellence (NICE) has been presented as politically independent, asserting it is free from industry influence and conflicts of interest so that its decisions may be led by evidence and science. We consider the ways in which soft political factors operate in guideline development processes at NICE such that guidelines are not truly led by science. We suggest that while NICE procedures explicitly incorporate scientific principles and mechanisms, including independent committees and quality assurance, these fail to operate as scientific practices because, for example, decisions may only be challenged through the courts, which regard NICE as a scientific authority. We then examine what the NICE rapid guideline procedure for COVID-19 reveals about the practical reality of claims about the scientific integrity of NICE guidelines. Changes to guideline development processes during the COVID-19 emergency demonstrated how easy it is to undermine the scientific integrity of NICE's decision-making. The cancellation of the guideline programme and the publication of a rapid guideline process specifically to address the COVID-19 pandemic removed scientific checks and balances, including independent committees, stakeholder consultation and quality assurance, demonstrating that the relationship between NICE and the UK government is more complex than a scientific principle truism. We suggest that NICE is not (and indeed cannot be) truly independent of government in practice, nor can it be truly led by science, in part because of its relationship to the state, which it is simultaneously constituted by and constitutive of.

Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme 'Early Adopter'

BACKGROUND

Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.

METHODS

A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.

RESULTS

Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.

CONCLUSIONS

Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.

Challenges and chances for local health and social care integration – Lessons from Greater Manchester, England

Purpose

Sustainability and transformation partnerships (STPs) were introduced to England, asking 44 local areas to submit their health and social care plans for the period from October 2016 to March 2021. This study aims to offer a deeper understanding of the complex structure in the local practice, and to discuss the associated challenges and chances.

Design/methodology/approach

Documentary analysis, qualitative interviews and questionnaire survey are used for this study. Findings have been compared and analysed thematically.

Findings

The study participants reported that apart from pooled budgets, past collaborative experience and local leadership are crucial elements for transforming health and social care integration in Greater Manchester (GM). Also, this study provides policy recommendations to promote effective collaborative partnerships in local practices and mitigate local inequity of funding progress.

Research limitations/implications

The findings of this paper cannot be extrapolated to all stakeholders due to the limited samples. Meanwhile, some of the discussions about the case of GM may not be transferrable to other STPs.

Originality/value

This study argues that the success of pooled budgets is the result, rather than the cause, of effective negotiations between various stakeholders; and therefore, there is no evidence suggesting that pooled budgets can resolve the discoordination of health and social care. Moreover, due to the bottom-up approach adopted by STPs, more effective boroughs tend to receive additional funding, resulting in an increasing gap of development between effective and ineffective boroughs.

Associations between density and quality of health promotion programmes and built environment features across Jerusalem

BACKGROUND

Health promotion programmes (HPPs) have the potential to influence individual health, depending on their quality and characteristics. Little is known about how they interact with built environment features and neighbourhood demographics in cities with substantial health disparities.

METHODS

Using the European Quality Instrument for Health Promotion (EQUIHP), we assessed the quality of HPPs, operating between 2016 and 2017, among adults aged 18-75 in Jerusalem. Areas were characterized by ethnicity and area socioeconomic level. Health information (body mass index, physical activity level) was obtained from the city profile survey. Geospatial information on the location and length of walking paths and bicycle lanes was obtained. Spearman correlations were used to assess associations among variables.

RESULTS

Ninety-three HPPs operating in 349 locations in Jerusalem were identified. Programmes were unevenly distributed across urban planning areas (UPAs), with the highest density observed in the southwest, areas populated mainly by non-orthodox Jewish residents. However, the best performing HPPs based on EQUIHP score were in the north and east UPAs, inhabited primarily by Arab residents. At a neighbourhood level, characteristics of the built environment positively correlated with higher total EQUIHP scores: the ratio between walking lane length to the neighbourhood's population size (r = 0.413, P < 0.001) and length of bicycle lane per population (r = 0.309, P = 0.5). Median EQUIHP score negatively correlated with the number of programmes per neighbourhood size (m2) (r = -0.327, P = 0.006) and neighbourhood average socioeconomic status (SES; r = -0.266, P = 0.027).

CONCLUSIONS

Our findings suggest that higher quality HPPs were preferentially located in areas of lower SES and served minority populations in Jerusalem.

Assembling the Healthopolis: Competitive city-regionalism and policy boosterism pushing Greater Manchester further, faster

Health and care policy is increasingly promoted within visions of the competitive city-region. This paper examines the importance of policy boosterism within the political construction of city-regions in the context of English devolution. Based on a two-year case study of health and social care devolution in Greater Manchester, England, we trace the relational and territorial geographies of policy across and through new "devolved" city-regional arrangements. Contributing to geographical debates on policy assemblages and city-regionalism, we advance a conceptual framework linking crisis and opportunity, emulation and exceptionalism, and evidence and experimentation. The paper makes two key contributions. First, we argue health and care policy is increasingly drawn towards the logic of global competitiveness without being wholly defined by neoliberal political agendas. Fostering transnational policy networks helped embed global "best practice" policies while simultaneously hailing Greater Manchester as a place beyond compare. Second, we caution against positioning the city-region solely at the receiving end of devolutionary austerity. Rather, we illustrate how the urgency of devolution was conditioned by crisis, yet concomitantly framed as a unique opportunity by the local state harnessing policy to negotiate a more fluid politics of scale. In doing so, the paper demonstrates how attempts to resolve the "local problem" of governing health and care under austerity were rearticulated as a "global opportunity" to forge new connections between place, health, and economy. Consequently, we foreground the multiple tensions and contradictions accumulating through turning to health and care to push Greater Manchester further, faster. The paper concludes by asking what the present crisis might mean for city-regions in good health and turbulent times.

Boundary organising in healthcare: theoretical perspectives, empirical insights and future prospects

Purpose

The purpose of this paper is to introduce a special issue on boundary organising in healthcare bringing together a selection of six leading papers accepted for presentation at the 12th Organisational Behaviour in Health Care (OBHC 2020) Conference.

Design/methodology/approach

In this introductory paper, the guest editors position the special issue papers in relation to the theoretical literature on boundaries and boundary organising and highlight how these contributions advance our understanding of boundary phenomena in healthcare.

Findings

Three strands of thinking – practice-based, systems theory and place-based approaches – are briefly described, followed by an analytical summary of the six papers included in the special issue. The papers illustrate how the dynamic processes of boundary organising, stemming from the dual nature of boundaries and boundary objects, can be constrained and enabled by the complexity of broader multi-layered boundary landscapes, in which local clinical and managerial practices are embedded.

Originality/value

The authors set the scene for the papers included in the special issue, summarise their contributions and implications, and suggest directions for future research.

Research implications/limitations

The authors call for interdisciplinary and multi-theoretical investigations of boundary phenomena in health organisation and management, with a particular attention to (1) the interplay between multiple types of boundaries, actors and objects operating in complex multi-layered boundary systems; (2) diversity of the backgrounds, experiences and preferences of patients and services users and (3) the role of artificial intelligence and other non-human actors in boundary organising.

Practical implications

Developing strategies of reflection, mitigation, justification and relational work is crucial for the success of boundary organising initiatives.

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

Agreeing the allocation of scarce resources in the English NHS: Ostrom, common pool resources and the role of the state

A challenge facing health systems such as the English National Health Service (NHS), which operate in a context of diversity of provision and scarcity of financial resources, is how organisations engaged in the provision of services can be encouraged to adopt collective resource utilisation strategies to ensure limited resources are utilised in the interests of service users and, in the case of tax funded services, the general public. In this paper the authors apply Elinor Ostrom's work concerning communities' self-governance of common pool resources to the development of collective approaches to the utilisation of resources for the provision of health services. Focusing on the establishment of Sustainability and Transformation Partnerships (STPs) in the English NHS, and drawing on interviews with senior managers in English NHS purchaser and provider organisations, we use Ostrom's work as a frame to analyse STPs, as vehicles to agree and enact shared rules governing the allocation of financial resources, and the role of the state in relation to the development of this collective governance. While there was an unwillingness to use STPs to agree collective rules for resource allocation, we found that local actors were discussing and agreeing collective approaches regarding how resources should be utilised to deliver health services in order to make best use of scarce resources. State influence on the development of collective approaches to resource allocation through the STP was viewed by some as coercive, but also provided a necessary function to ensure accountability. Our analysis suggests Ostrom's notion of resource 'appropriation' should be extended to capture the nuances of resource utilisation in complex production chains, such as those involved in the delivery of health services where the extraction of funds is not an end in itself, but where the value of resources depends on how they are utilised.

Patient and public involvement in priority-setting decisions in England's Transforming NHS: An interview study with Clinical Commissioning Groups in South London sustainability transformation partnerships

BACKGROUND

Patient and public involvement (PPI) in health-care commissioning decisions has always been a contentious issue. However, the current moves towards Sustainability and Transformation Partnerships (STPs) in England's NHS are viewed as posing the risk of reducing the impact of current structures for PPI.

OBJECTIVE

To understand how different members in clinical commissioning groups (CCGs) understand PPI as currently functioning in their decision-making practices, and the implications of the STPs for it.

DESIGN

Thematic analysis of 18 semi-structured interviews with CCG governing body voting members (e.g. clinicians and lay members), non-voting governing body members (e.g. Healthwatch representatives) and CCG staff with roles focussed on PPI, recruited from CCGs in South London STPs.

RESULTS

There are contestations amongst CCG members regarding not only what PPI is, but also the role that it currently plays and could play in commissioning decision making in the context of STPs. Three main themes were identified: PPI is 'going out' into the community; PPI as a disruptive power; and PPI as co-production, a 'utopian dream'?

CONCLUSIONS

Long-standing issues distinctive to PPI in NHS prioritization decisions are resurfacing with the moves towards STPs, particularly in relation to contradictions between the rhetoric of 'partnership' and reorganizations that foster more top-down control. The interviews reveal pervasive distrusts across a number of levels that are counterproductive to the collaborations upon which STPs rely. And it is argued that such distrust and contestations will continue until a formalized space for PPI in STP priority-setting is created.

McKinsey and the 'Tripartite Monster': The Role of Management Consultants in the 1974 NHS Reorganisation

The first major reorganisation of the National Health Service took place in 1974, twenty-six years after the service had been established. It has long been perceived as a failure. This article draws on archival records and a witness seminar held in November 2016 to provide a more nuanced assessment of the 1974 reorganisation and understand more fully why it took the form that it did. In particular it identifies the reorganisation as an important moment in the ongoing story of management consultants engaging with health policymakers, and explores the role of McKinsey and Co. in detail for the first time. Key explanatory factors for their involvement are identified, including the perceived lack of expertise and manpower inside the civil service and the NHS, and perceptions of their impact and effectiveness are discussed. Many debates about the use of management consultants today were directly foreshadowed during the early 1970s. Alongside this, the role of other groups of policy actors, including civil servants, politicians and medical professionals, are established and the extent to which British health policymakers have had to work within existing cultural, political, legislative and practical constraints when trying to initiate change is demonstrated. The fact that many of the 'mistakes' that were made have been repeated in the course of subsequent reforms, speaks to the poor institutional memory of Whitehall, and the Department of Health and Social Care in particular. In the run up to 1974 management consultants could make only a limited contribution to an imperfect compromise.

Challenges in integrating health and social care: the Better Care Fund in England

Objectives

The Better Care Fund is the first and only national policy in England that has legally mandated the use of pooled budgets to support local health and social care systems to provide better integrated care.

Methods

We report qualitative findings from the first national multi-method evaluation of the Better Care Fund, focusing on its implementation, perceptions of progress and expected impacts among key stakeholders. Interviews were carried out with 40 staff responsible for Better Care Fund implementation in 16 local health and social care sites between 2017 and 2018.

Results

Study participants reported their experiences of implementation, and we present these in relation to three themes: organizational issues, relational issues and wider contextual issues. Participants stressed the practical and political challenges of managing pooled budgets and the complexity of working across geographical boundaries. In a context of unprecedented austerity, shared vision and strong leadership were even more vital to achieve collaborative outcomes.

Conclusion

Pooling budgets through the Better Care Fund can lever closer collaboration between sectors and services. Shared vision and leadership are essential to develop and foster this closer collaboration. Although some successes were reported, the study highlights that there are major cultural, operational and territorial barriers to overcome.

Regional assemblage and the spatial reorganisation of health and care: the case of devolution in Greater Manchester, England

In this paper, we examine how space is integral to the practices and politics of restructuring health and care systems and services and specifically how ideas of assemblage can help understand the remaking of a region. We illustrate our arguments by focusing on health and social care devolution in Greater Manchester, England. Emphasising the open-ended political construction of the region, we consider the work of assembling different actors, organisations, policies and resources into a new territorial formation that provisionally holds together without becoming a fixed totality. We highlight how the governing of health and care is shaped through the interplay of local, regional and national actors and organisations coexisting, jostling and forging uneasy alliances. Our goal is to show that national agendas continued to be firmly embedded within the regional project, not least the politics of austerity. Yet through keeping the region together as if it was an integrated whole and by drawing upon new global policy networks, regional actors strategically reworked national agendas in attempts to leverage and compete for new resources and powers. We set out a research agenda that foregrounds how the political reorganisation of health and care is negotiated and contested across multiple spatial dimensions simultaneously.

Political discourse in the hospital heterotopia

To what extent do we pay attention to the text and images that cover our hospital walls and do we offer any critique either as professionals or service users? In the past we might have expected to see functional or helpful instructions about where to go (or not to go) and in more well-endowed buildings, perhaps we would see some works of art, sculpture, stained glass even, with the intention to encourage, distract or even forewarn us. However, it is now common in UK hospitals, for wall space to be used as a  portal for a range of institutional political messages, that convey information about everything from its own values, behaviours to  advertisements for products and services to requirements for rule following. Michel Foucault's ideas about Heterotopic space can help us to see that hospitals tend to fall (awkwardly) between being a public and personal health care space, and this is a possible explanation for the confused material culture and messages that are shared there. This paper draws on ethnographic methods to reflect on personal experience in order to offer a critique of the contemporary political discourse which has become 'literally' written onto our hospital walls.

What is the relevance of policy transfer and policy translation in integrated care development?

Purpose

The purpose of this paper is to document the influence of policy transfer on integrated care development, its global occurrence and shifts towards integrated care. It highlights the influence of supranational forces, and the roles and relevance of policy transfer and policy translation in the development of integrated care.

Design/methodology/approach

This paper presents the findings of an international review of the policy transfer of integrated care, and the relevance of policy translation in integrated care development.

Findings

The global occurrence in integrated care, as evinced in this paper, can be seen in the global shift towards integrated care in various countries. However, studies exploring the actual mechanism of policy transfer and policy translation in relation to integrated care across countries are limited. The study of integrated care through the lens of policy transfer is important, as it for example, explores the structural elements, including environmental and cognitive obstacles in the policy transfer process. Policy translation offers a social constructivist approach to explore the travel of ideas, and considers the multiple spatial and scalar contexts in which integrated care policy is implemented.

Originality/value

This paper aims to advance policy transfer and policy translation as complementary frameworks to explain integrated care development. Second, it seeks to make novel and useful contributions to the debate about the development of integrated care, and to the wider arguments on policy transfer and policy translation and integrated care in other parts of the world.

NHS Activism: The Limits and Potentialities of a New Solidarity

Using Thompson's conceptualization of the moral economy, I describe how NHS activists in the UK utilize moral arguments to form alliances between different occupational groups, in a political battle against health care privatization, reflecting how a consciousness is being built upon solidarity and shared interests. In this context, professional duties of health care professionals are linked to the interests of all citizens. I explore how the deployment of professional ethics elides a moral hierarchy that may hinder the movement's egalitarian potential.