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Pushing poverty off limits: quality improvement and the architecture of healthcare values

Research output: Contribution to journalArticlepeer-review

Polly Mitchell, Alan Cribb, Vikki A. Entwistle, Guddi Singh

Original languageEnglish
Article number91
JournalBMC Medical Ethics
Issue number1
Accepted/In press28 Jun 2021
Published13 Jul 2021

Bibliographical note

Funding Information: We have argued that limited constructions of clinical professional roles and ethics risk being reproduced by healthcare institutions. In particular we have highlighted the potential for quality discourses and practices to contribute to this process. The way the language and architecture of quality and QI tend to operate under managerial influence within health services can, we have argued, act as an obstacle to genuine broadening of clinical agendas. The objects of QI are constrained by institutional boundaries, making it difficult to operate with ends and goals that are not health-related in this constrained sense. This is not an inevitable problem—budgets and systems could be less siloed—but it is a problem in practice. Moreover, moving to partnership working which is supported by shared financial and institutional structures is liable to be very difficult and present other challenges [, , ]. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.


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    Uploaded date:30 Jun 2021

    Version:Accepted author manuscript

    Licence:CC BY

King's Authors


Background: Poverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people’s lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative (PSI) into paediatric practice using the discourse and methodology of healthcare quality improvement (QI). Discussion: Whilst suggesting that interventions like the PSI are a potentially valuable extension of clinical roles, which take advantage of the unique affordances of clinical settings, we argue that there is a tendency for such settings to continuously reproduce a narrower set of norms. We illustrate how the framing of an initiative as QI can help legitimate and secure funding for practical efforts to help address social ends from within clinical service, but also how it can constrain and disguise the value of this work. A combination of methodological emphases within QI and managerialism within healthcare institutions leads to the prioritisation, often implicitly, of a limited set of aims and governing values for healthcare. This can act as an obstacle to a genuine broadening of the clinical agenda, reinforcing norms of clinical practice that effectively push poverty ‘off limits.’ We set out the ethical dilemmas facing clinicians who seek to navigate this landscape in order to address poverty and the social determinants of health. Conclusions: We suggest that reclaiming QI as a more deliberative tool that is sensitive to these ethical dilemmas can enable managers, clinicians and patients to pursue health-related values and ends, broadly conceived, as part of an expansive range of social and personal goods.

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