This chapter stakes out the field for a sociological analysis of changes in health care systems as part of modernisation processes. The concept of citizenship provides the framework to link the issues of regulation and welfare state policy to the study of professions and professionalism. Linking citizenship and professions brings the state back into the study of professions, and in turn, professions into social policy and health care research. This new perspective on the governance of health care moves beyond the controversies between market, state and professional self-regulation. It highlights the role of the professions as mediators between the interests of the body of citizens/state and the individual (research design step I, see Figure i.1). Attention is also directed to the tensions between a global ‘superstructure’ of governance and the various ways in which states translate this superstructure into practice. I will start with the relationship between professionalism and citizenship and will then come to the current changes, namely consumerism and the calls for integrated care. New approaches in the sociology of professions are discussed; research on complementary and alternative medicine (CAM), as well as midwifery, serve as examples to outline the intersections, tensions and contradictions between state regulation, professional interests and consumer choice. Finally, some preliminary conclusions are drawn as to how to assess current developments in health care in such a way that brings different sets of dynamics into focus, and furthers context-sensitive theoretical approaches.

Citizenship as a superstructure of governance

Citizenship functions as a superstructure of governance. It is both the normative backdrop and a symbol of modernisation processes in Western societies. Dating from the 18th century and continuously developed and transformed under the welfare state system, the concept of citizenship has seen a revival and is currently undergoing yet another transformation within the context of European integration (Bottomore, 1992; Hall and Soskice, 2001; Clarke, 2005). It promises to bridge the contradictions of markets and social equality, of diversity and unification as well as bureaucratic regulation and self-determination.

In health care we can observe the transformations of citizenship ‘in action’ and assess the promises of social inclusion (Saks and Kuhlmann, 2006: forthcoming). A closer look at this superstructure might provide a promising starting point to gain deeper insights into the underlying order of current developments in health care, its limitations, challenges and options for change.