NHS Activists, Managers and Ideological Closure

Since 2010, a Conservative³ national government has severely restricted English NHS⁴ funding and has made significant changes in policy and structure. Several groups have campaigned against these changes. For my doctoral research, I spent thirteen months doing participant observation with these political activists in various parts of Greater Manchester. I spent the greatest amount of time with a group in a relatively well-off suburb that I will call ‘Dunning’. I refer to the group as ‘Dunning Keep Our NHS Public’ (Dunning KONP).

I was aware of the group before I carried out my fieldwork. I am an NHS doctor, and had worked at Dunning Hospital before. When junior doctors undertook industrial action in 2016 (Pushkar 2019), Dunning KONP was one of the groups that supported our pickets. During fieldwork, I became a regular attendee of Dunning KONP's Tuesday-morning protests outside Dunning Hospital. I joined them for other protests in Dunning, as well as in other parts of Manchester and even London, attended their monthly organising meetings, helped with stalls in Dunning town centre, and joined their social gatherings. I also conducted semi-structured interviews with nine of Dunning KONP's members, often in their homes or in local pubs. Including other areas, in total I interviewed twenty-two activists, some of them two or three times.

They contested proposed transformations of NHS services on the basis that reforms may lead to cuts or privatisation, which would be wrong in so far as they would cause the state to forego its obligation to provide welfare services for all people in the country. The primary focus of my participant observation was with activists. But the key ‘interpretive battles’ (Ginsburg 1989: 96) were between activists and state actors⁵ – managers and politicians – advocating reforms. Therefore, activists often attended open meetings of the councils, the clinical commissioning groups (CCGs) and the hospital trusts. I attended some of these meetings as well. I also joined NHS activists when they organised private meetings with managers or politicians. I often heard managers and politicians speak at conferences or on TV, and read what they had said in newspapers. But most of my data with these state actors came from interviews.

I interviewed nine managers. These managers were mostly employed in senior positions of control at CCGs, hospital trusts and the Greater Manchester Health and Social Care Partnership (GMHSCP). I also interviewed twelve politicians, of whom eleven were local councillors and one was a Member of Parliament (MP). These state actors were ‘local’ in that they were based in and responsible for areas in Greater Manchester. By describing them as local, I counterpose them with the managers of the whole English NHS, and politicians in government, responsible for the country. This comparison is particularly important because most local politicians were Labour, whereas the government was Conservative. All of the politicians quoted in this article were Labour. Not all of the activists in Dunning KONP supported Labour, but they did all vehemently dislike the Conservative Party.

My contention is not that state actors did not have ethical aspirations. As Laura Bear and Nayanika Mathur (2015) have highlighted, bureaucrats’ utopian aspirations and the ways in which they do or do not act to realise them can be fruitful terrain to analyse the pressures at play for social groups, including the bureaucrats themselves. I found that managers and politicians often used the same ethical discourse as activists to describe the values of the NHS and underpin their political action: ‘free’, ‘universal’, ‘comprehensive’. However, managers and politicians sought to realise these values within the financial constraints that were the precise point of contention for campaigners.

Activists took the issue of financial constraints and spoke about the morality of them, in order to expose them to debate. They made the moral political by arguing that proposed reforms would result in foregoing the state's obligations to its citizens.⁶ Managers claimed to have the same values as activists, but sought to narrow the space within which moral judgements could be made, in order to confine the space of political debate. Bureaucrats had already decided what was possible within enclosed limits. Further challenges to their plans were to be shut down. Debate was foreclosed.

I call this placement of boundaries around what was achievable ‘ideological closure’. Giving it a name begs the question: what drove the ideological closure of these managers? The word ‘closure’ suggests resolution,⁷ as in the closure sought after the end of an intimate relationship. But this article will describe closure as a process. I will describe how processes of enclosure and foreclosure facilitated ideological closure, tending towards but never quite achieving resolution, leaving cracks open for the ethical imagination of the people charged with administering audit practices. The argument of this article is that they had to be coerced to constrain their moral arguments against service retrenchment, to deem their responsibility to spend within their allocated budgets as more important than other responsibilities.

Anthropological Literature on Accountability

Anthropological studies of accountability have generally focussed on audit cultures, defined by Cris Shore and Susan Wright as ‘the widespread proliferation of … calculative rationalities of modern financial accounting and their effects on individuals and organizations’ (2015: 421). They follow a Foucauldian framework whereby they expose a regime of truth in which quantitative indicators and measurements have become increasingly pervasive in the organisations that they investigated: universities. These measurements became important both as instruments for universities to use within their own internal governance, but also in their external representations of quality and efficiency. The transparent exposition of such measures was supposed to demonstrate best practice to stakeholders such as employees and students, who would thus have the means by which to hold the university to account.

Shore and Wright were interested not just in how audit culture reshaped organisational accountability, but also in audit as a totalising technology of contemporary life that had become widely institutionalised through the practices of New Public Management (NPM). NPM's use of audit encouraged staff and students not just to understand the accountability of the university in terms of measurable outcomes, but also to apply the same understanding of accountability to themselves as individuals. Staff were encouraged to understand their responsibilities as employees through a prism of accountability that could be conceived through calculable inputs and outputs, for which they were responsible as individuals.

As political and managerial processes were reshaping individual subjectivities in this way, ranking technologies were reshaping the organisation and work of universities according to whatever was being ranked. Thus, audit became inescapable as the pursuit of good practice – measured by pre-set quantitative outcomes to be transparently assessed, recorded and presented – became self-justifying, even as it overrode and stripped away professional autonomy. Shore and Wright thus drew a comparison with Weber's iron cage of bureaucracy, instead referring to audit as the ‘“glass cage” of coercive transparency’ (2015: 422). However, this was not literal coercion, but a quasi-coercion through disciplinary processes; the responsible subject was both being formed and (re)forming herself, auditing herself in cognisance of being audited by her superiors.

For Shore and Wright, audit is a top-down technology of accountability, ‘as those in positions of power seek to make legible the performance of those below them’ (2015: 429). The auditees, in this case professional academics, object to the obvious imbalance of transparency and accountability by invoking their professional ethics. But as Marilyn Strathern (2000) notes, and as Shore and Wright reiterate, managerial indicators were often very difficult to oppose precisely because they co-opt and redefine professional values such as responsibility, quality, self-management and transparency.

Responses (e.g. Amit 2015) to Shore and Wright's 2015 article, ‘Audit Culture Revisited’, noted a contradiction in their analysis of audit. Shore and Wright described audit as totalising and inescapable, but also recognised the unevenness of the transformations it had wrought. Casper Jensen (2015) expanded the idea, pointing out that audit's promoters may well intend it to be totalising but that audit never quite manages to engulf all other social processes and achieve unidirectional progress. Therefore, Jensen was keen for researchers to keep their eyes open for the other dynamics at play. In addition, Katherine Teghtsoonian (2015) raised the puzzle of the audit juggernaut: if it is neither totalising nor particularly effective at even achieving its explicit goals (such as improved quality or efficiency of delivered services), then why do governments and managers continue to have faith in it? This article provides one response to this puzzle. Managers stick to audit practices because they are forced to do so by their own managers.

Social Policy and Health Services Literature

In 1987, Patricia Day and Rudolf Klein described the welfare state as the ‘service-delivery state’ (1987: 1). In this conceptualisation of the state, certain actors were responsible for delivering a suite of services within a budget set by their superiors. These state actors may fail in their responsibilities (e.g. to a promise, or to uphold their own duties or professional ethics, or simply to balance the books). But being held accountable for such a failure would be a separate step that implies a relationship (to a person or electorate, to a regulatory body, or to an auditor / line manager). Day and Klein describe how managers and politicians had to find ways to stretch increasingly limited resources to provide the services expected by citizens while remaining answerable for the nature of those services.

The techniques of audit devised and implemented by the service-delivery state – performance indicators, targets, outcome assessments – later crystallised under NPM, which was defined by Christopher Hood and Ruth Dixon as a ‘a set of loosely related ideas about government and public service reform … ostensibly intended to create “a government that works better and costs less”’ (2015: 265). Hood and Dixon (Hood 2010; Hood and Dixon 2015) were amongst many (e.g. Bezes et al. 2012; Hewison 2002) who researched NPM and found negative consequences in terms of the outputs of the organisations involved: lower productivity, increased costs, more complaints. But scholarly critique of NPM did not slow it down; NPM continued to expand within the NHS throughout the 1990s and 2000s, closely tied to the politics of neoliberalism. Although social policy and health service researchers such as Day, Klein and Hood often focussed on organisational outcomes rather than individual subjectivities, the structural processes they were observing were the same ones that Shore and Wright (2015) investigated in universities. Within the context of NPM, audit and financial accountability became the means by which neoliberal reforms were effected in many state and state-funded structures, including healthcare, social services, schools and higher education.

At the same time as the flourishing of NPM, the complexity of the organisation of service provision also continued to increase, as recognised by the House of Commons Committee of Public Accounts in 2016 (Hammond et al. 2018). The reforms that have taken place in the NHS over the past decades, and especially since 2012, have created a confusing mish-mash of organisations.⁸ Figure 1 depicts the institutional hodgepodge, making lines of accountability difficult to follow. With so many organisations existing – many new, many often referred to by three-letter acronyms – even internal actors such as managers and clinicians had difficulty keeping up with who was responsible for what.

Screenshot taken from How Does the NHS in England Work? An Alternative Guide, a video made by CreativeConnection for the King's Fund, published on 6 October 2017. The screenshot depicts the complex relationship between national government (in Westminster), local government (through local authorities), NHS England, CCGs, healthcare providers, patients and related bodies, such as NHS Improvement and social-care providers. The diagram includes bodies that had been proposed at the time but never achieved full realisation, such as Sustainability and Transformation Plans and Accountable Care Organisations. https://www.kingsfund.org.uk/audio-video/how-does-nhs-england-work-alternative-guide-2017.

Citation: The Cambridge Journal of Anthropology 41, 1; 10.3167/cja.2023.410109

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Screenshot taken from How Does the NHS in England Work? An Alternative Guide, a video made by CreativeConnection for the King's Fund, published on 6 October 2017. The screenshot depicts the complex relationship between national government (in Westminster), local government (through local authorities), NHS England, CCGs, healthcare providers, patients and related bodies, such as NHS Improvement and social-care providers. The diagram includes bodies that had been proposed at the time but never achieved full realisation, such as Sustainability and Transformation Plans and Accountable Care Organisations. https://www.kingsfund.org.uk/audio-video/how-does-nhs-england-work-alternative-guide-2017.

Citation: The Cambridge Journal of Anthropology 41, 1; 10.3167/cja.2023.410109

• Download Figure

Screenshot taken from How Does the NHS in England Work? An Alternative Guide, a video made by CreativeConnection for the King's Fund, published on 6 October 2017. The screenshot depicts the complex relationship between national government (in Westminster), local government (through local authorities), NHS England, CCGs, healthcare providers, patients and related bodies, such as NHS Improvement and social-care providers. The diagram includes bodies that had been proposed at the time but never achieved full realisation, such as Sustainability and Transformation Plans and Accountable Care Organisations. https://www.kingsfund.org.uk/audio-video/how-does-nhs-england-work-alternative-guide-2017.

Citation: The Cambridge Journal of Anthropology 41, 1; 10.3167/cja.2023.410109

• Download Figure

Central government remains nominally in control of the overall function of the NHS, supposedly to be held to account at general elections. When a central body is supposed to be in charge of a number of different organisational actors, questions are raised as to how and when to exert or threaten hierarchical control. Health services researchers have investigated these questions internationally and found that the difficulty in making such judgements has led to ‘pendulum swings’ (Axelsson 2000: 47) between central control and decentralisation. Jonathan Hammond and colleagues, investigating the purported swing back towards decentralisation in the NHS⁹ at the time of my fieldwork, note that ‘[s]uch attempts to redistribute power from central government to agencies and localities provide fertile conditions for “blame games” … “buck-passing”, and accountability ambiguity when objectives are not met’ (2018: 1151).

The focus of Hammond and colleagues’ study is NHS England, an arms-length body set up by the Health and Social Care Act 2012 ostensibly to allow the NHS to be run by experts with a long-term mandate, rather than being subject to ‘political interference’ or ‘micro-management’ by meddling MPs with short-term electoral goals.¹⁰ However, health ministers continued to influence NHS England (Timmins 2018), albeit in the absence of transparency. Hammond and colleagues (2018) found multiple formal and contractual technologies of accountability upwards to NHS England, such as assurance demands, the NHS Outcomes Framework and key performance indicators. As a result of these measures, bureaucrats working in local organisations such as CCGs described their experience in terms of constraint rather than the autonomy that might be expected with decentralisation. On the other hand, accountability downwards to patients and the public was more limited and unclear.

Hammond and colleagues found that rather than protecting the NHS from government, NHS England served to ‘insulate government ministers from unpopular policies, thus shifting, or obscuring, the locus of accountability’ (2018: 1152). Government set the ‘rules of the game’ (2018: 1148), but it was NHS England that enforced the rules. In so doing, NHS England highlighted the difference between responsibility and accountability, as well as the political importance of such a difference. That is, while government ultimately was responsible for many of the decisions that were driving changes to the NHS, NHS England obscured how people related to it and thus how they could hold it accountable. Providers of care had a direct relationship to NHS England rather than to government, and accountability mechanisms worked through that relationship. Since the accountability relationship with government was unclear, Hammond and colleagues argued that a process of ‘depoliticisation’ (2018: 1163) was taking place. Government was creating policies and driving transformations, and people's contestation of such reforms was defanged by government's insulation by NHS England.

My ethnographic account will go into more detail on how people were experiencing the above processes. Activists were deeply frustrated by managers and politicians failing to acknowledge responsibility for their decisions and actions. Members of Dunning KONP and Greater Manchester KONP could see that the NHS was struggling, that the services being offered were diminishing and deteriorating; they predicted that further cuts and privatisation would make things even worse, and they wanted to hold someone accountable for these undesired happenings. Meanwhile, they heard managers and politicians at all levels speak only about the achievements of the NHS and the positive results of current and future reforms, not the negative consequences that exercised activists.

Accountability as Answerability

In the eyes of campaigners, the people most responsible for NHS reforms were the Tory national government and the senior managers in London that had been appointed by that government. Although they spoke of holding those politicians accountable, they were aware that the primary mechanism for democratic accountability of Westminster politicians came at general elections. That would mean waiting several years, during which time the same politicians continued to exert an influence over the NHS that these activists considered to be detrimental. Frequently, I heard them say: ‘We cannot wait for an election’.

Of course, democratic accountability does not only manifest at elections. Activists and other members of the public expected MPs to answer for their actions and inactions to show that they had understood the consequences thereof. To illustrate this type of accountability – as answerability – I describe a public meeting organised by Bolton KONP in November 2017, at which a panel of mental health professionals, activists and service users spoke to residents of the area. One person on the panel was a mother, Jess, who spoke of the tragic death of her son, Jordan. He had sought help at the local emergency department when he felt suicidal. After waiting for three hours, he had been assessed by a mental health practitioner and then discharged with no follow-up arranged. A few weeks later, his suicidal thoughts returned. He went to a park and hung himself. He died.

The organiser of the meeting, Olga, was herself a mental health nurse, as well as a union and KONP activist. After the mother had finished speaking, Olga said to the audience:

You may be thinking: how could this happen? Actually, this kind of story is far from exceptional. It happens far too often. We are the fifth-richest country in the world. We are not a poor country. But we choose to starve our NHS, especially mental health, so much that we have such a poor service that people's experience is such that they end up in this kind of situation.

Rather than focus on the role of the clinician who saw Jordan, or the clinician's managers, Olga allocated responsibility upwards, to the government that had made fiscal decisions that shaped the environment in which that clinician worked. She did implicitly acquiesce to a sense that the trust was at fault, but also pointed towards the many other people failed by trusts across the country. How could this happen? Because trusts did not have enough money to employ enough staff. And responsibility for that lack of funds lay with the national government. People like Jordan were suffering the consequences of decisions taken by politicians in Westminster.

Olga's allocation of responsibility upwards created a moral antagonist: the Tory government. Bolton had a Tory MP who had voted for many of the cuts that people were angry about. Therefore, Olga suggested that on Saturday we march to his office for his weekly constituency surgery. The plan was to explain the story to him, since

He should know what he's signing his name to when he says the health service can't have any more money. When people walk away from services because they can't face the wait, because of what he has done, he should face that. He should know what he's doing. It's heartbreaking when you hear that, isn't it? He should hear that.

It was clear to Olga that the MP was at least partially responsible for this death, as well as many others. But until he acknowledged his responsibility, until he was made to answer for his failure to uphold that responsibility, he had not been held to account.

They did not get an answer. The MP did not meet them, and did not acknowledge that he or the government played a role in the death. (Nor did he agree to be interviewed by me, or reply to my emails.)

Accountability as Transparency

Getting an answer implies asking a question. But activists often told me that part of what was so troubling about recent reforms of the NHS was not just the cuts and privatisation, but that it was so difficult to work out what had been cut or privatised. Thus, the question itself was difficult to formulate. The Health and Social Care Act 2012 had not just made the division of NHS structures much more complex (as per Figure 1). The new commissioning arrangements meant that it was often very difficult for someone to know which of their local NHS services were no longer being provided, being provided with a reduced remit or fewer staff, or being provided by a private company. Moreover, any contract that an organisation held to provide a service to the NHS would not be visible to the public. It would be protected by commercial confidentiality. But the complexity of the contracts and the dynamic ecology of service provision did not just make healthcare structures unintelligible for activists, patients and citizens. Politicians also found it difficult to keep up with how the NHS worked, and how it was changing. Almost every MP and councillor I spoke to admitted to not fully understanding the NHS.

The relative ignorance of councillors was a recurring theme amongst the activists that I spent time with. Activists oscillated between a desire to ally with, educate and help these politicians to understand current and future structures, and exasperation at councillors resisting their explanations and offers of help. Meanwhile, councillors ploughed on with the reforms that campaigners felt would facilitate privatisation. Dunning KONP and Greater Manchester KONP members knew that the chief architects of reforms were in London, people like then Secretary of State for Health and Social Care, Jeremy Hunt, and then Chief Executive of NHS England, Simon Stevens. But they had no avenues through which to engage with Westminster managers and politicians. They could only engage with – to hold accountable – the people with whom they had more of a relationship, local managers and politicians. Hence their vexation when these people did not acknowledge the risks that activists explained to them, instead focussing on the need for reforms, which they trumpeted as positive changes.

When I spoke to managers and politicians privately, they did acknowledge that responding to budgetary constraints was a key driver for the reforms they were advocating, because limited finances were simply ‘the reality’. They also acknowledged the risks that activists voiced. But they did so quietly, without allowing the acknowledgement of such risks to deter their path.

Nor did managers and politicians often speak about cutting hospitals as a goal of reforms. This lack of explicitness was part of what activists referred to when they said the plans were far from transparent. On the rare occasions when politicians were explicit regarding such plans, activists were shocked. One member of Dunning KONP, Debbie, told me several times of when she heard a senior Manchester councillor speaking at an NHS Innovation conference. She shuddered in disbelief when he said that he looked forward to a time when Manchester would be able to ‘reduce its hospital provision’, that is, to shut hospitals. I asked that councillor about this when I interviewed him. He explained the same arguments that I had heard from managers and politicians around the city: that hospitals were bad places for people to recover from illness, due to the risks of muscle-wasting, of hospital-acquired infections, of iatrogenic injury. It would be better for patients, as well as cheaper, to treat those people in their own homes.

I replied: ‘I think everyone would probably welcome a service that was able to keep people out of hospital … I think the anxiety [of activists] is that the hospital beds might be cut before we've got to … ’ He cut me off to say: ‘Yeah, I understand that. The purpose, as part of the … scheme in agreeing the Transformation Fund, was basically to establish double-running so that we could set up the new services at the same time as the old services continuing to run, to basically address that question quite directly’. He was referring to a time-limited pot of money that had been allocated to Greater Manchester by NHS England to allow it to set up new community services at the same time as still running the hospital services. The fund was for £450 million, ending in 2021. The theory was that while there was still money in the pot, there would be no need to close hospitals. Thus, there would be enough time for the community services to be fully established and reduce demand for hospital beds before those beds were lost.

I wondered about the fears of activists and professionals (e.g. Royal College of Emergency Medicine 2017) that the presence of these new community services would not actually reduce demand for hospital services. I asked: ‘And if, when the Transformation Fund comes to an end, when it's run out of money, community services have been upgraded and that hasn't reduced demand on hospital beds, what happens then?’ He replied: ‘Yeah, we're in the shit’.

When pushed, managers and politicians had to acknowledge the risks to which they were exposing the NHS. At the time of writing, in 2022, we know that demand did place severe pressure on NHS capacity before the pandemic, and then did outstrip capacity during the first and second waves of COVID-19 infections, leading to avoidable deaths (Calvert and Arbuthnott 2021; Pollock and Harding-Edgar 2020; Thomas 2020). As of October 2022, the waiting list for elective care has breached 7 million people, with the median wait time being 13.8 months (Wilkinson 2022). The waiting list is expected to continue growing until at least 2024. So why were managers and politicians taking these risks, and doing so without full explanation to the public? If their actions were driven by an ideological closure in which they accepted fiscal austerity as simply ‘the reality’ rather than a political decision that could be contested, that does not explain the part that really annoyed NHS activists: managers’ and politicians’ unerring public positivity regarding NHS reforms and their reluctance to speak out regarding the inadequate funds for either maintaining the service as it was or for carrying out the kind of reforms they were advocating.

Corporate Accountability

In the opening vignette, Betty described why she did not feel able to speak openly regarding the reasons that NHS services were struggling to keep up with demand. She feared losing her job. I learnt about how this threat of losing one's job loomed over managers’ decisions regarding their own discourse from Julian, a doctor as well as a senior manager in Dunning. Shortly before I interviewed him, he had been called to give evidence to Dunning Council's Health and Social Care Scrutiny Committee. At the meeting, he had said that cuts to the public health budget were irrational and went against the council's stated strategy of keeping people well in the community and thus reducing demand for hospital beds. Members of Dunning KONP had been present at the meeting and had reported his comments back to other members. The next time Dunning KONP members went to a council cabinet meeting, with the Leader of Dunning Council present, they used the opportunity to ask him a question in which they directly quoted Julian.

In my interview with Julian, he told me that his frank criticism of public health budget cuts had caused some friction that led him to believe that his job was in jeopardy. I told him that Dunning KONP had directly quoted him in their communication with the Leader, and he described such communication as ‘eminently appropriate … It probably does not help enamour me to the Leader, but nonetheless, it's something that they are absolutely entitled to do. I mean, there would be no point in claiming a freedom to speak if people didn't have a right to quote you’. Julian had an acute sense of the conflicting accountabilities in his professional life. He was aware of his corporate accountability to his employer, as well as his professional accountability to his patients. As a public health consultant, his patients were effectively the whole population of Dunning. He summarised the situation:

I am accountable for my management decisions to my line manager in the council, to the Chief Executive … And [as] a manager, you have to do what the organisation requires you to do. That's quite clear. It's the role of advising the public that's the issue because there I see myself as a doctor advising a population and … I'm accountable to that population.

However, unlike hospital doctors who have direct encounters with their patients, he did not meet his patients. Therefore, it was not clear how they might hold him accountable. The regulator for doctors, the General Medical Council (GMC), stipulated what his professional duties were and could hold him accountable to those duties.¹¹ But he felt his responsibility to protect and promote the health of Dunning's population went beyond just what the GMC said. Thus, his professional ethics were enforced not just through upwards accountability to the GMC, but also through his own conscience, his sense of obligation and duty:

As far as giving professionally correct advice to the population, and as far as giving professionally correct advice to the agencies that serve the population, that is something that I think I have an obligation to do. And I don't accept that I'm accountable to anybody for it … I think duty is more important than accountability.

Although he had initially told me that he was accountable to the population, he was very aware that this downwards accountability was impossible for that population to enforce. Thus, it could easily be overridden by his upwards accountability to his employer. Having noted this possibility, he was able to protect and prioritise his obligation to the people through moral reasoning that relied on an institution of ethics other than accountability: professional ethics.

However, this process of moral reasoning was still vulnerable. He told me: ‘If you have a duty to give advice, then the ideal is that your organisation accepts that and therefore it doesn't create any conflict between that duty and [corporate] accountability’. But in his career, there had been eight times that he recalled when duty and accountability came into conflict, thus placing his employment in peril. He included the current situation in those eight times. Unlike other managers that I spoke to, Julian had foreseen that there would be times when his accountability to his employer might threaten his ability or desire to do what he considered to be the right thing. Therefore,

I very deliberately, during my late thirties and early forties, lived modestly and saved and invested my salary in order to have what I think in the private sector is – somewhat inelegantly – called ‘fuck you money’ … I have always, from my early 40s, been in a position where I could walk away if I had to. And there have been times over the years when, if I had not had ‘fuck you money’, I would not have had the courage I've had.

His moral reasoning against corporate accountability relied on his professional ethics. Aware that professional ethics would be difficult to hold to if his line manager had the ability to cut his professional contract, Julian spent years building a protective wall of savings around his professional ethics. Unlike Betty, Julian did not have a mortgage that placed such restrictive limits on how he translated his moral reasoning to practical actions and public discourse, but only because he had put time and effort into protecting his moral reasoning from the coercive force of corporate accountability.

That is not to say that Julian's savings gave him complete freedom. He told me that part of a manager's role was to contribute to corporate strategy. But once the organisation had decided its plan, the manager ought to stick to it most of the time, even if he had been advocating for something different to what was eventually chosen. The times when Julian felt compelled to speak out against the council's actions had been exceptions that he could count on his hands. Moreover, when I asked if he could tell me more about them in our interview, he said no. Although he had spoken out in those incidents, he had not spoken out willy-nilly. He had chosen particular ways to make his voice heard in order to effect a change in direction that complied with his own understanding of his and the council's moral obligations. Telling me more about them in 2018 would not have been a useful way to address those past conflicts, and so he remained quiet.

Some of my other interlocutors found other ways of protecting themselves and their consciences. Olga, the nurse who organised the public meeting in Bolton, was dismissed from her role as a senior nurse in a mental health trust in 2007. She felt she was sacked as a result of her open criticism of the cuts being made at the time. I also spoke to an administrator in cancer care, Nancy, who had been suspended in the early 2000s due to her criticism of her manager's plans to change the pay structure within the trust. Both Olga and Nancy were union activists seeking protection and strength in numbers through collective action.

They both developed counter-arguments to their managers’ plans. Olga's reasoning brought together moral arguments regarding worsening care for patients with self-interested arguments regarding mental health practitioners’ terms and conditions of work. In Nancy's case, she was also criticising a plan that would have had a deleterious effect on staff terms and conditions. In the union, one more accountability relationship was added, since Olga and Nancy were accountable to fellow employees. For Olga and Nancy, as holders of positions in their unions, they had a responsibility to contest changes that would have a negative effect on pay and work conditions. That is, Olga and Nancy were allied with other members of their respective unions. Their senses of responsibility were the basis of their reasoning, leading them to oppose the more senior managers.

But both Olga and Nancy were heartened to see that other union members also felt accountable to them, as evidenced by these other employees taking action to protest their dismissals. It was the collective organisation of the union that insulated them from corporate accountability. That is, whereas Julian had relied on his savings to have the courage to follow his professional ethics rather than corporate coercion, Olga and Nancy relied on the workplace bargaining power of the union to have the courage to follow reasoning that fulfilled their union responsibilities.

Illegibility and Ideological Closure

In the Accountability as Transparency section, I discussed the inability of activists to hold people accountable for changes to the NHS, since the changes were not visible to them. The changes were hidden and thus illegible. Strathern (1997), one of the earliest theorists of audit cultures, discussed how one of the aims of audit was precisely to make organisations legible. The legibility she described was according to a particular model, thus facilitating the use of measures to describe the degree to which the organisation fitted a pre-set ideal. Where an organisation did not fit the model, auditors did not attempt to understand what the organisation actually did. Instead, the lack of fit between the auditors’ findings and the audit technology's model led the auditors to conclude that the organisation was ‘somehow … not there’ (1997: 9). While she found the lack of curiosity allowed within audit ‘extraordinary’ (1997: 9), she also found a potential sanctuary for creativity. Perhaps if auditors were not looking – or, rather, were unable to see – then academics and other professionals could let their ideas run free.

But illegibility has a different function in the cases discussed here, in which activists were not auditing bureaucrats but utilising other forms of accountability. Activists were attempting to render managers’ and politicians’ actions transparent and hold them answerable for those actions. Unlike auditors, activists were far from incurious regarding what the organisations were doing and how they were going about it. However, activists were actively blocked from learning about service retrenchment and its consequences. Whom did this illegibility protect? Strathern wondered if the illegibility (to audit) of some professional activities might afford scholars freedom to act in line with motivations other than those measured by auditors. However, I found that in NHS transformations the mish-mash of accountabilities and professional or moral codes was different. Rather than protecting the creative professional from the diktats of auditing managers, illegibility protected the manager from the morally enervated activist. Illegibility was one way in which debate regarding the appropriateness or goodness of reforms was foreclosed. Thus, the manager could get on with counting beans and reforming services within the enclosed limits of the available beans.

However, Betty, Julian, Nancy and Olga did not simply get on with counting beans. Upwards accountability was partially blocked, shielding bureaucrats from political challenge, foreclosing debate. As such, Betty and Julian were aware of activist discourse but had only had occasional meetings with activists. But managers and politicians were moral agents themselves. They were accountable to their own consciences and internalised ethical codes. At times, they reasoned that despite fulfilling an obligation to spend within one's means the transformations they were administering were failing on other obligations that they considered at least as important, such as to provide universal, free and comprehensive healthcare to all. Therefore, the enclosure of conceptualisations of what could be achieved was broken, occasionally leading to an openness to debate. Julian broke open the foreclosure of political debate through his own moral reasoning.

It is this combination of enclosure and foreclosure that I have described as ideological closure in this article. It was closure – with the appearance of a debate that had already been settled and could not be reopened – that so enervated activists, who were attempting to prise it open. Julian, Olga and Nancy all demonstrated that ideological closure did have cracks; alternatives were possible.

Conclusion

The evidence from NHS management is salutary in shedding light on the puzzle of whether or not audit was a totalising force. In fact, multiple accountabilities butted up against one another. Activists mobilised moral arguments in their political action, attempting to hold someone accountable for organisational reforms that they considered to be wrong. The bureaucrats administering reforms evaded engagement with such arguments, citing the simple reality of constrained budgets. The managers had to balance the books.

But in interviews, the moral discourse of managers demonstrated that the disciplinary technologies of audit were not quite enough to enforce willing compliance. Their ethical imagination was not entirely enclosed, their openness to debate was not entirely foreclosed. Ideological closure was not wholly achieved. Audit could not eliminate contingency on its own. For Betty, the coercive pressure exerted through corporate accountability was required to enforce neoliberal transformation. It was the upwards accountability from periphery to centre, from locality to London, from trusts and CCGs to NHS England and central government that stood out above other accountabilities and gave order to the mess. Central government was able to take advantage of a line of accountability from local managers and politicians all the way upwards to NHS England and the Department of Health and Social Care in Westminster that cut through all the other competing accountabilities, giving it the appearance of being inescapable.

Describing bureaucrats’ justifications of their choices as ideological closure illuminates how they formed moral arguments in favour of service retrenchment: they were constrained by the reality of less money. This article goes further by explaining why they formed such arguments. They were coerced under a previously scarcely examined rubric of neoliberal accountability: corporate accountability to one's employer. Rather than Andrea Muehlebach's (2012) moral neoliberal self, I have described the line-managed neoliberal bureaucrat, her morality constrained within the menacing confines of the terms of her employment. If ever her moral reasoning suggested the capacity to build links and alliances with activists and the wider public, she was pressured such that her loyalty had to remain to the upwards accountability to the centre.

My account of coercion being necessary to force actors to shut up and get on with enforcing cuts, even when they had ideas that such restrictions might not be the best course of action, goes some way towards answering Teghtsoonian's (2015) puzzle. To recall, she asked why the use of audit continued to expand, despite evidence of it failing to improve outcomes or efficiency. In my fieldwork, I found that managers did so because they were made to. And the same coercive pressure stopped them from engaging in debate. Betty told me that ‘none of us are going to [speak out ourselves] because we all want to keep our jobs, and not get into trouble’. But even this coercion did not achieve the totalising influence that was once claimed of audit. Julian, Nancy and Olga did speak out, albeit unevenly and with reservation. They called upon various personal and social resources to do so. In the end, contingency remained. These managers were able to carve a space in which they could imagine the future of the NHS with greater freedom than a truly totalising force would have allowed.