Moral economy and the NHS: the normative dimension of service reconfiguration

Smith, Christopher Quartermaine (2021). Moral economy and the NHS: the normative dimension of service reconfiguration. University of Birmingham. Ph.D.

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This thesis refines and applies the concept of moral economy to understanding a large-scale service reconfiguration in the NHS. It draws on a qualitative case study informed by critical realism, enabling an enhanced understanding of the way structural forces interact with the moral dimension of NHS organisations. The thesis provides a new sociological perspective on the role of moral beliefs in NHS service change, while developing a distinct moral economy framework which can be applied more widely.

The thesis explores how to conceptualise moral economy with greater precision than existing accounts; how to operationalise the concept into an empirical study; and how to understand the dynamics underpinning moral beliefs and decision making under conditions of organisational change. It is argued that moral economy should be conceived as the study of how moral phenomena are entwined with structural relations of political and economic power. Within this, the ‘moral’ side of moral economy needs to be seen as consisting of a range of multi-level phenomena. This distinguishes between morality as a property of social context and as a property of individual subjectivity. With this understanding established, critical realist metatheory is deployed to further develop moral economy for the purpose of studying organisations. Here multiple types of moral and economic phenomena are identified and integrated into a single theoretical framework using a modified version of Abend’s (2014) moral background. This enables analytical distinctions to be made between the different aspects of morality and structural relations of power, as well as specifying how they interact via reflexive human agents.

This theoretical framework is applied to an empirical case study of a large-scale, inter-organisation service change in the NHS, drawing primarily on interviews with those involved in planning and implementation. It is revealed that a range of moral phenomena – on both contextual and individual levels – interact to create a strong consensus about what is right within the service change. The thesis analyses this multi-level morality in terms of a particularly subtle mode of entwinement of the moral and economic: epistemic governance. The refined moral economy framework developed illuminates how moral beliefs within institutions are underpinned by complex, interdependent webs of meanings, ethical commitments, regulations and power structures. As such, the thesis develops an original approach to moral economy which is particularly well suited to understanding how moral and economic phenomena interact as part of the process of service reconfiguration in the NHS. Through exploring the influence of structure, culture, agency, and social power on individual beliefs and judgements, this thesis also provides a novel sociological perspective on the normative dimension of organisational change.

Type of Work: Thesis (Doctorates > Ph.D.)
Award Type: Doctorates > Ph.D.
Licence: All rights reserved
College/Faculty: Colleges (2008 onwards) > College of Social Sciences
School or Department: School of Social Policy, Department of Social Policy, Sociology and Criminology
Funders: Economic and Social Research Council, Other
Other Funders: University of Birmingham
Subjects: H Social Sciences > HM Sociology


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