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Collective harms - harms resulting from the aggregate actions of numerous agents - challenge standard approaches to establishing moral accountability. It is commonly claimed that an agent is not accountable for something that she did not individually cause, or to which she individually could have made no difference. However, in cases of collective harm, claims are frequently made about the accountability of individual agents across the cone of causation. This thesis develops an approach to making sense of these competing claims. I explore a range of accountability theories to identify where each succeeds (or fails) in populating the catchment of consideration - the pool of candidates for downstream moral assessment - and in providing explanatory value. I begin with a representative version of the standard individually directly causal account. I then change the subject of accountability from the natural person to more complex agents - joint agents and corporate agents. Next, I change the basis of accountability from causation to Kutzian participation. Finally, I set out a new conception of participation - a model I call Participation on its Own Terms. In each case I apply the model to examples drawn from a detailed account of a significant real-world collective harm: the Global Economic Crisis of 2007-9. I argue that adopting a pluralistic (supra-model) approach to applying these models makes it possible to broaden the catchment of consideration for accountability for the crisis to a few million contributions of varying magnitude. This approach produces a breadth of coverage better aligned with standard pre-theoretic views while avoiding the trap of making everyone responsible. At the same time, the application of each model contributes substantively to our explanation of how the crisis occurred. Furthermore, this supra-model approach broadly applies to other collective harms, such as the production of inequality, structural injustice, and human-driven climate change.

Some innovations are termed ‘disruptive’, a designation that is normally applied to technology; examples include computers, digital cameras, and mobile phones. The term can also be applied to groups of workers, particularly if they are able to offer specific technical capabilities within a market at lower cost, but broadly equal and effective to that offered by traditional products or services. Paramedics could be described in this way and are a newly professionalised group, with distinctive capabilities in terms of responding to the needs of not just the acutely ill and injured, but increasingly those patients with undifferentiated non-life- threatening conditions, which increasingly make up the bulk of 999 call demand. The key to their transition from an artisan, skilled worker to professional status is the acquisition of certain ‘hallmarks’. Perhaps the most important of these is the completion of more prolonged education that affords the opportunity to graduate with enhanced decision-making and other clinical skills in order to meet the needs of the full spectrum of patients in the pre-hospital setting. Paramedics were surveyed to determine how they rated their ‘traditional’ preparation and to establish what their attitudes were to a more educationally based approach. Paramedics themselves proved to be realistic regarding shortcomings in established training and education systems, while also being strongly motivated to learn more within a higher education setting, particularly if this additional effort would result in being able to offer a wider range of care to their patients. During the study, major changes in the health care environment and the role of the Ambulance Service took place, leading to a requirement to undertake a second phase of research. This took the form of ‘Horizon Scanning’ in an attempt to detect ‘signals’, themes and trends in relation to newly emerging ‘competitors’ to the paramedic role. These included nursing, new practitioners and most critically, the rapidly emerging medical sub-speciality of pre-hospital care, staffed by medical personnel on a pattern found specifically in some European countries, sometimes termed the ‘Franco-German’ model/System (FGM/S). Hitherto, the model of provision in the UK had followed the ‘Anglo-American’ model/System (AAM/S), approach, with paramedics providing direct patient care in the field and medical staff largely involved in medical oversight, teaching, clinical governance and other higher level roles. As part of this research, the evidence base for change was examined and consideration given to the factors that might help clarify what the likely situation could be in 2030 in respect of ambulance services, pre-hospital care and paramedics. This future is uncertain, but factors have been identified that would militate in favour of one or other model prevailing, with close links established between educational preparation, system design, career structure and the continuance of the professionalisation process favouring paramedic progression. However, other factors, most specifically professional power, the absence of a clear evidence base and an apparent reluctance to clearly acknowledge this in some respects, lead to the conclusion that the future of pre-hospital care remains uncertain and contested, but also potentially amenable to a well-directed influencing strategy.