This chapter juxtaposes the conceptualisation of responsibility in the key documents for the reform of healthcare systems in the regions of the North of England and Northern Ireland, with the views of research participants from those spaces and places, which suggest a more diverse, and sometimes complicated and contradictory understanding of responsibility. Through the discussion, we have identified a gap between the conceptualisations, with responsibility as accountability for ill health being dominant in the reform documents. This signals the privileging of the epistemic communities through which both the dominance and gap arise, which may be composed of experts drawn from wealthier regions or backgrounds (than those of our participants). This dominance excludes the patients from those regions from contributing to the knowledge on which the reform proposals are based. As such, this suggests how these patients become subject to structural prejudice, or at least dominance and oppression, relating to their identity, within the very conceptualisation of responsibility underpinning the documents, and hence hermeneutical marginalisation and injustice. Such structural prejudice or dominance may also engender testimonial injustice towards those patients, since their views on responsibility may also be given less credence, further compounding their exclusion from contributing towards the shared knowledge underpinning the reforms. Patient understandings of responsibility, if built into law and policy, may help reduce the conditions for epistemic injustice. This in turn would help to ensure a distribution of responsibility and accountability between patients, on the one hand, and the state and its healthcare institutions on the other, that actually reflects more accurately what those patients want and need their healthcare systems to deliver.