Converging hybrid worlds? Medicine and hospital management in Europe

Converging hybrid worlds? Medicine and hospital management in Europe

Article Type: Guest editorial From: International Journal of Public Sector Management, Volume 27, Issue 5

For some time now, the reorganisation of health care provision has remained high on the public agenda throughout the western world, with governments introducing quasi-markets, privatising service supply and experimenting with new methods of funding services (McKee and Healy, 2002). Concomitantly, there has been a growing interest in changing the internal governance of health care organisations. In particular, hospitals, being focal provider organisations of health care, have been subject to various pressures to reform their managerial arrangements such that the pre-existing relations between medicine and management are in the process of being radically reconfigured. This special issue of the IJPSM brings together a collection of timely papers that explore these changes and reflect the work of a European network of academics involved in health care research (Cost action IS0903: “Enhancing the Role of Medicine in the Management of European Health Systems”[1]).

The assumption of researchers and policy analysts has long been of hospitals being “remarkably resistant to change, both structurally and culturally” (McKee & Healy, 2002, p. 8). Hospitals were inter-related systems of professions, with a leading group of physicians shaping the internal organisation (Abbott, 1988; Freidson, 2001; Coburn, 2006). This distinctive set of agents were seen to control the work, training and professional development of subordinate groups, and, in many instances, also investment policies and the planning process of the entire organisation.

This was in marked contrast with other modern organisations modelled on typical rational designs, with individual managers governing a complete chain of organisational operations (Mintzberg, 1983). True, hospitals too had grown into highly formalized undertakings, exhibiting sophisticated arrangements for internal governance (Heydebrand 1973) and being exposed to multiple stakeholders. Yet overall, administrative power in hospitals appeared weak if compared to other types of modern organisations (Ackroyd et al., 1989).

However, the leadership of the medical professions came under pressure with wider changes in the governance of western welfare states. The mantra of “New Public Management” and, together with this, the proliferation of new blueprints for the governance of service-providing enterprises have markedly challenged the managerial arrangements in and around public service-providing organisations. This has often been referred to as the advent of “managerialism” in public sector settings, or as a shift from a professional culture to a managerial one (Kirkpatrick et al., 2005; Mannion et al., 2005; Clarke and Newman, 2009). Governments and other regulatory agencies have sought to introduce new managerial tool-kits, with a key objective being a specialisation in “the organisation and co-ordination of services and the consideration of efficiency in service delivery” (Ackroyd, 1995, p. 342).

This new “Management” was believed capable of leading large complex organisational units (Lega and De Pietro, 2005, Koelewijn et al., 2012). Those taking on the role of a manager needed to specialise on such matters and possess sufficient authority to make their managerial decisions effective. Moreover, this leadership was conceived as “problem-solving” management, rather than the deployment of creativity and the demonstration of professional excellence. Hence it corresponded less to the prestigious position of the classical head of department in the “good old days” of medical professionalism. The emphasis was placed on both micro-economic and administrative accountability, with budgetary concerns given a critical role. Moreover, the new “managerialist” approach chimed with a strong belief in organisational steering based on numbers, incentives and sanctions.

Overall, there has been a strong cultural shift regarding the internal governance of hospitals. In some countries, this shift translated directly in a revamped hospital organisation. Thus, England has seen a strong drive to enhance the management role of doctors; new leadership positions were created, following a “Clinical Directorate model” (Llewellyn, 2001, pp. 597-598) through which managers with medical expertise were given a remit to oversee the process of health care holistically (Forbes et al., 2004). Similar arrangements have been rolled out in Italy (Lega, 2008). Internationally, budgetary and administrative issues became more salient in medical work, notwithstanding differences regarding the influence of health care managerialism (Simonet, 2011).

Managerial concepts inspired by this line of thinking have been welcome by some and opposed by others (Numerato et al., 2012). On the one hand, there was a perception that clinical practice had long remained indifferent vis-à-vis management tasks, ignoring the reality that the needs of patients have to be met in a context of finite resources. It is partly for this reason that funders and regulators have endorsed the “managerialisation” of hospital governance. There were also voices saying that merging medical and managerial responsibilities would provide better conditions for innovation. These were drawing on studies meant to demonstrate the benefit of hospital managers having a medical background (Dwyer, 2010; Goodall, 2011). Others, however, argued that managerialisation made doctors become distracted from their genuine task of healing patients or are even enticed to prefer economic issues over medical ones, with one result being the colonisation of medical professionalism (Caronna, 2011). Hence there were concerns about medical orientations being “crowded out” by a technocratic and business-like management approach.

Today, changing arrangements in the governance of hospitals are an irrefutable fact. However, the study of this movement is still in its infancy (but see Dent, 2003; Jacobs, 2005; Kirkpatrick et al., 2009; Koelewijn et al., 2012). In particular, the way these arrangements are remoulded, and the extent to which doctors adopt leadership functions embracing responsibilities including micro-economic issues, deserve greater attention. Extending traditional professional roles tends to blur the cognitive boundaries of professional work, possibly even changing attitudes towards power, and challenging basic professional values. Furthermore, micro-economic or administrative steering on the one hand, clinical leadership on the other do not always sit easily with one another, and this may entail new tensions in hospital management.

Noordegraaf (2007) has referred to the aforementioned developments as a “transition from “pure” to “hybrid” professionalism” (Noordegraaf, 2007, p. 761; see also Kurunmäki, 2004; Jacobs, 2005). Among other things, the lead references of the medical profession are exposed to a competing micro-economic logic (Reay and Hinings, 2009). Importantly, once there is hybridity multiple patterns of behaviour, role-taking and strategy development become conceivable as ingredients of the managerial arrangements (Currie et al., 2012). Accordingly, there are many ways of implementing organisational change in hospitals, and there may also be various ways by which doctors can cope with those countervailing rationales inherent in management roles extending beyond mere medical concerns. In short, the hybridisation of managerial arrangements is subject to high procedural contingency that varies from country to country.

This contingency is rooted in various imponderables. Thus, doctors are often very resistant to taking on managerial responsibilities, especially those centering on the administration of budgets as this is perceived to imply a rationalisation of provision (Numerato et al., 2012). Doctors feel their medical authority challenged and tend to use available discretion to circumvent newly imposed obligations, even in case they embark on the new “management track”. Some seek options for treating patients according to their own professional references “undercover”, e.g. by contextualising diagnostic or therapeutic decisions in a specific manner (Vogd, 2011, pp. 315-341; Currie et al., 2012). This may help them preserve “soft autonomy” within the organisational context of hospitals (Levay and Waks, 2009).

Furthermore, the introduction of new management models is prone to trigger role conflicts or disruption in the collaboration between different professional groups. This may occur where other professions (such as nurses) are invited to take on leadership roles as, for example, in Norway (see Berg, 2014; Byrkjeflot and Jespersen, 2014 in this special issue). Elsewhere, a shortage of doctors may seriously inhibit doctors taking on managerial functions, as appears to be the case in Poland (see Hartley and Kautsch, 2014, pp. 430-440).

More generally, professional roles and the normative foundations they are based on are subject to distinctive national environments. Comparative work on the development of professions (including the medical one) has often highlighted differences in their positions, conceptualization and evolution according to distinctive national trajectories (Johnson et al., 1995, Dent, 2003, Kuhlmann and Burau, 2008). Hence the changing interface between medicine and management is likely to be highly encultured.

Importantly, a lot of variety persists regarding the (political) regulation of the hospital sector (Blank and Burau, 2010; Simonet, 2011). Path dependency – a key issue to comparative public policy (Wilsford, 1994; Pierson, 2000) – applies to the development of hospital systems as well. Both the regulatory frameworks and the related mind-sets of stakeholders in these systems are nation-specific in many respects. Thus, in countries with a national health system (e.g. Italy, England), a hospital sector can be subject to a top-down “management reform” much more readily than in systems based on multi-stakeholder arrangements (Germany, France). Also, lump-sum funding schemes (based on DRG-type systems), while being a reality in many European health care systems, exhibit important differences regarding their range, the way they work, and the organisational settlements to which they apply (Cookson and Dawson, 2012).

Likewise, there are various models of quasi-market governance which has become an international phenomenon in health care provision. For example, German hospitals have by tradition been subject to a purchaser-provider split scheme (involving the so-called sickness funds); it is, then, less this scheme as such but the way it intersects with the long-established economic independence of hospitals that make governance change (Bode, 2013). In France; DRG funding has been introduced too, but in contrast to Germany, the bulk of hospitals have not (yet) been exposed to a situation where success in the competition for cases (to treat) is the dominant mechanism of resource allocation (Cordier, 2008). While in England, pressures thus far come from a centrally controlled internal rather than an external market – although this may change in the near future (Mays, 2011).

These observations are in line with the argument that public management reforms have impacted differently within various countries (Dent, 2003; Pollitt and Bouckaert, 2007; Simonet, 2011). It is no surprise then that early evidence on the development of medical-manager-roles bears witness to European hospital sectors exhibiting dissimilar evolutionary dynamics (Jacobs 2005; Kirkpatrick et al., 2009). The new hybridity in the governance of hospitals appears to adopt a multi-fold character. Whereas it is enshrined in the model of clinical directorates in some countries (Fitzgerald and Ferlie, 2006), it elsewhere seems to be associated with doctors maintaining medical roles and acquiring, in addition, some accounting expertise (Kurunmäki, 2004).

Therefore, as new management models are rolled out within distinctive institutional structures and traditions, there is a lot of institutional contingency in the way managerial role roles are evolving in contemporary hospitals, including for doctors. In other words, the afore-sketched developments correspond to various institutional particularities within a given system. Among those system-related factors that could make a difference regarding the encounter of medicine and management are the strength and type incentives for doctors to enter management roles; the supply for medical labour; the role of the private sector; the influence of other than the medical professions; the way public policies impinge on the hospitals’ development policies; or the dissemination of tools for controlling and accounting throughout a given hospital sector.

Due to this twofold set of contingencies, there is considerable variety in the new hybrid world of hospital governance – more precisely, in how managerial arrangements, and the role of doctors therein, can evolve internationally. At the same time, however, both concepts to overcome existing institutional traditions and managerial fads and fashions travel cross-border, with an international soundboard for management reforms and organisational reengineering as a result. A distinctive management model may not be applied everywhere in Europe, yet there probably exists functional equivalents showing a similar impact regarding the internal governance of hospitals. In a word, the developments mentioned at the outset have indeed created a common European reform agenda, yielding similar challenges to the various stakeholders of hospital management, in general, and to doctors, in particular.

A deeper understanding of how the relations between medicine and (hospital) management are currently evolving requires insights in the highly nation-specific developments regarding the aforementioned factors. The sample of case studies contributed to this special issue promises many new insights regarding these relations, including with respect to the above mentioned set of contingencies. They shed light on national path-dependencies, but also on local or sub-sectoral dynamics by which the encounter of doctors and management is shaped within a hospital system. What is more, they may also sharpen our understanding of how procedural contingency is influenced by institutional factors. Such analysis may relate the latitude of doctors to adapt or refuse or transform managerial roles to distinctive regulatory developments, for instance. Or it may show how the very contents of managerial functions depend on the regulation of hospital care in terms of marketisation and central planning.

Themes of the articles

This special issue, delving into the institutional and procedural contingency shaping the evolution of managerial arrangements across Europe, contains four articles on national configurations, one comparative paper, and one conceptual contribution.

(1) Berg and Byrkjeflot explore the development in Norway where various reforms have been launched in order to introduce new, more hierarchical management structures. They focus on accountability relationships and examine how the reforms have affected physicians and nurses and their involvement in management. It is shown that physicians who traditionally have been in charge of the hospitals have met competition from other health professions, especially nurses who have found a new career option here and have entered leadership positions that imply responsibilities for budgets and human resource management. While this is in accordance with their holistic view on leadership, many doctors feel that being a manager is a trap. However, some physicians take a stronger interest in management and see it as a new career track. Hence, a new, albeit uneasy, architecture of internal governance has started to take shape.

(2) Bode and Märker present findings from research undertaken on German hospitals. They show that the importance of management in medicine is generally increasing, with more managerial (administrative) functions becoming included in the clinicians’ day-to-day activities. However, the medical profession itself is very hesitant about any greater involvement in administration task or managerial functions. What is more, policies of hospital owners matter. Some of the latter are critical to the development of arrangements through which doctors are awarded greater managerial responsibility. Overall, the development of governance structures has proven highly diverse, ranging from the establishment of medical subunits as autonomous profit centres to a sophisticated command-and-control scheme that puts medical departments in a subordinate position.

(3) In his article, Vinot sheds light on recent changes in the management model of French public hospitals, especially those following a reform enacted in 2009. This reform has strengthened the managerial roles not only of top leaders, but also the heads of medical poles of clinical activities. The paper explores whether there has been any increase in power of these “Chefs de Pole” and whether this will entail any path-breaking change in the governance of hospitals. At the local level, the degree to which doctors are involved in the management process depends on their embeddedness in the established internal networks; prestige and “clan involvement” is highly important in determining the actual managerial power of these doctors.

(4) In the article on doctor-in-management roles in Italy, Lega and Sartirana inspect the actual situation regarding the managerial involvement of hospitals doctors in Italy. They argue, hybrid leadership roles (in which management and medicine are merged) have been formally introduced in Italy as a consequence of financial constraints and pressures to reinforce clinical governance and to foster internal collaboration. The “medical-management roles” that have emerged have been highly formalized, in particular the position of the clinical director. The authors posit that the new leadership model has in many cases not brought about the promised benefits, due to flawed implementation and a lack of adequate skills of professionals. This, they argue, may change in the future.

(5) The comparative contribution, written by Hartley and Kautsch, looks at the evolving medical-manager-roles within England and Polish health systems. Their paper explores whether or not there is any convergence between the two systems. Both countries have undergone wide-reaching reforms since the 1980s, with the hospital sector becoming ever more market oriented in both countries. Drawing on Freidson's (1994) re-conceptualisation of professionalism and the centrality of collegiality, the article demonstrates the ways in which reform has led to greater medical involvement in management in England and altered traditional notions of collegiality, whilst there are early signs that established medical-management positions in Poland are becoming less attractive, with new forms of collegial organisation starting to emerge.

(6) The final contribution, written by Byrkjeflot and Peter Kragh Jespersen (who sadly died recently) provides a literature review on the various ways the concept of hybrid management. The authors suggest a typology of the relationship between professionalism and managerialism (commercialised, clinical, neo-bureaucratic manager). Hospitals are seen as a showcase for contemporary hybrid public sector agencies.

Altogether, the papers included in this special issue provide us with illustrative examples of the rich range of the variation in medical hybridisation that is, and in some cases, is not going on within the hospitals across Europe. The “managerialisation” in hospital care that has blurred the boundaries between medicine, management and clinical leadership exhibits a national character. The variety and complexity regarding this movement appears considerable. There are top-down management reforms in some countries (UK, Italy, Norway and France) while elsewhere “managerialisation” is an emergent and less clear-cut process (Germany, Poland). The worlds of hospital governance converge as a general tendency, but there is considerable contingency in the related physician-management encounter.

Dr Ingo Bode
Department of Social Policy, Law and Sociology, University of Kassel, Kassel, Germany

Professor Mike Dent
Faculty of Health, Staffordshire University, Stafford, UK

Note

For further information on the work of this COST Action see: http:// www.dr-in-mgmt.eu/

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Further reading

Ferlie, E., Ashburner, L., Fitzgerald, L. and Pettigrew, A. (1996), The New Public Management in Action, Oxford University Press, Oxford

Hugman, R. (1998), “Social work and de-professionalisation”, in Abbott, P. and Meerabeau, L. (Eds), The Sociology of the Caring Professions, UCL Press, London, pp. 178-198

Sehested, K. (2002), “How new public management reforms challenge the roles of professionals”, International Journal of Public Administration, Vol. 25 No. 12, pp. 1513-1538

Waring, J. and Currie, G. (2009), “Managing expert knowledge: organizational and managerial futures for the UK medical profession”, Organization Studies, Vol. 30 No. 7, pp. 779-802

About the Guest Editors

Mike Dent is a Professor of Health Care Organisation at the Faculty of Health Sciences, Staffordshire University in the UK. He is an organisational sociologist who has been researching, writing and publishing on the comparative organisation of health care and on the professions of medicine and nursing for more than two decades. More recently he has extended this interest to include user involvement in health and social care services and has been involved in research into e-health aspects of care pathways. Professor Mike Dent is the corresponding author and can be contacted at: mailto:mike.dent@staffs.ac.uk

Ingo Bode is a Professor at the department of Social Policy, Law and Sociology in the Faculty for Human Sciences at the University of Kassel (Germany). His areas of work are the comparative political sociology of welfare states and organisation studies in social and health care. Current research includes the changing governance of the hospital sector and international perspectives on networks in social service provision.