A matter of (good) faith?: Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration

Chris Q Smith; Iestyn Williams; Will Leggett

doi:10.1016/j.socscimed.2023.116553

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration

Chris Q Smith^*, Iestyn Williams, Will Leggett

^*Corresponding author for this work

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Abstract

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

Original language	English
Article number	116553
Journal	Social Science and Medicine
Volume	342
Early online date	24 Dec 2023
DOIs	https://doi.org/10.1016/j.socscimed.2023.116553
Publication status	Published - 1 Feb 2024

Bibliographical note

Acknowledgments
This paper is based on a doctoral research project carried out by the lead author and supervised by the co-authors. The first year was supported by a one-year studentship provided by the College of Social Sciences at the University of Birmingham. The second and third years were supported by a studentship from the Economic and Social Research Council (ESRC) Midlands Graduate School Doctoral Training Partnership [award reference - 1925667].

We would like to thank the Economic and Social Research Council (ESRC) and University of Birmingham for funding the research. We would also like to thank the anonymous reviewers for their constructive and helpful feedback on the paper.

Copyright © 2024 The Authors.

Keywords

Service change
Health service reconfiguration
Major systems change
Moral background
Epistemic governance
Sociology of morality
Qualitative research

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Cite this

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abstract = "Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.",

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