Kuhlmann, E. and Burau, V. (2009), "Managerial regimes meet the healthcare state: introduction and outlook", Journal of Health Organization and Management, Vol. 23 No. 3. https://doi.org/10.1108/jhom.2009.02523caa.001Download as .RIS
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Managerial regimes meet the healthcare state: introduction and outlook
Article Type: Guest editorial From: Journal of Health Organization and Management, Volume 23, Issue 3
This special issue sets out to explore the contingencies and dynamics of different policy flows emerging when new (post) public management regimes meet the “healthcare state” across different countries in Europe and beyond. Managerialism and the market logic characteristically act at the meso level of organisations and professionals, in particular through performance measurements, contractualisation, standard setting and quality assurance (for an overview see, Blank and Burau, 2007; Harrison and McDonald, 2008; Roberts et al., 2008). Managerial regimes are based on the logic of generic applicability and therefore do not take account of context. By contrast, the healthcare state is strongly shaped by historically developed welfare state arrangements (Moran, 1999; see also Freeman, 2000), including economic and cultural conditions, the specific mode of citizenship and the state-professions relationship. The new managerial governance practices therefore are likely to impact differently on healthcare states (Burau et al., 2007; Burau and Vrangbæk, 2008; Greer, 2008; Kuhlmann and Allsop, 2008).
In our introduction to the collection of articles in this special issue we open up the box of managerial regimes as a globe-spanning trend and universal mode of governing health professional groups, organisations and service users alike. By contrast, we approach the new managerialist governance in healthcare from different angles and highlight the significance of contexts. Our focus is on healthcare states as institutional settlements, which work as filters of managerial regimes. We seek to explore whether and how these filters are permeable and malleable through the strategies of professions, which traditionally enjoyed the capacity to “filter” policy flows. Further, we are interested in a broader range of settings beyond “government” – as represented in the formal institutions at the macro level of the healthcare state – and thus take a closer look at the meso level of the organisation of care and the micro levels of interaction with health professions.
We begin by discussing the role of the healthcare state in the wider architecture of changing governance and how the new managerial regimes are connected to strategy and agency of the professions. We then proceed by presenting the structure of this special issue and an overview of the individual contributions. In conclusion, this collection of articles makes several important contributions to existing studies of healthcare governance and management: first, the cross-country comparative perspective highlights the importance of institutions as filters for governance change; second, it places emphasis on professions as mediators of governance change at the meso and micro levels; and third, it highlights that governance is a highly complex enterprise that is not only targeted by state-professional configurations but also shaped by organisational settings, value systems and user expectations.
2. New settlements: healthcare states, managerial regimes and professions
Across countries state regulation is undergoing fundamental changes in all areas of public services, thereby mirroring what Clarke and Newman (1997) a decade ago described as the emergence of a “managerial state”. Healthcare is a particularly interesting field for exploring these developments. Here, ongoing economic pressures for cost efficiency meet with the demands on quality of care and safety of patients and the public, the latter traditionally ensured by the self-governing capacities of professions and the related state-profession arrangements. Consequently, in healthcare the implementation of management approaches and practices are not just another organisational model attempting to improve performance and accountability of professionals. Instead, managerial regimes mark a qualitative new form of governing the organisation and delivery of care that changes the classic model of state regulation and state-profession bargaining in various ways (see for instance, Allsop and Baggott, 2004; Hunter, 2006; Salter, 2007). An overall move towards managerialism and network-based and partnership governance are signs of an ongoing development towards the “re-shaping of the state from above, from within, from below” (Reich, 2002, p. 1669).
Viewed from this perspective it becomes clear that how managerialism in healthcare unfolds in practice needs to be assessed from different perspectives in order to grasp the various dimensions and potentially contradictory effects of changes emanating from “above”, “within” and “below” the healthcare state. Although an increasing body of research into managerialism in healthcare does exist (see, for instance, Bridges et al., 2007; Ford and Angermeier, 2008; McDonald et al., 2008), the different strands of the changing governance of healthcare remain poorly connected.
The concept of governance (Newman, 2001) provides a helpful umbrella connecting the various sets of governing and the related policy flows above, within and below nation states. A popular slogan that characterises governance as “governing without government” is certainly misleading (Rhodes, 1996). Following Newman’s (2005) analysis: “State power is not dissolved ( hierarchical forms of governance remain significant ( but the idea of the state as a unitary actor is problematised, with more emphasis being placed on market mechanisms, network patterns of governance (governing through partnership and collaborative strategies), and the constitution of citizens as self-governing, responsible subjects” (p. 81). When applied to “healthcare states” and the implementation of new forms of management, the concept of governance, however, needs further theoretical and empirical investigation (see, for instance, Burau et al., 2007; Kuhlmann and Saks, 2008).
One important issue for further consideration is the relationship between the formal institutions of the healthcare state and other governance practices and players in the policy process. Burau and Vrangbæk (2008), in a comparative study of five European health systems, remark on the persistence of hierarchical forms of governance, but are able to demonstrate that the relative balance between forms of governance varies among countries. They show that the specific configuration of particular governance practices shapes the scope for agency of the medical profession. The intersections between different sets of governance – and related to this the importance of a context sensitive theoretical and methodological framework – are perhaps even more complex when other than medical services are included. A cross-country comparison of home care services for elderly people, for example, reveals the significance of a highly complex and fluid set of culture/values, gender regimes and labour market incentives that interact with the formal institutions of the healthcare state and form a specific set of governance practices relevant in this emerging sector of healthcare (Burau et al., 2007).
Yet another related issue of governance theory in need of clarification when applied to healthcare is the role of the professions and their self-governing powers assured by the state. As described elsewhere in greater detail (Kuhlmann, 2006), professions are assigned to play a double role as the “officer” and the “servant” of welfare states; as a mode of governing occupational groups, professionalism hosts both self-interest and altruism. While the role of professions in society has always been shaped by a number of ambiguities and uncertainties, the classic ambiguities nowadays meet with the new “unsettled formations” of welfare states (Clarke, 2004) of which managerial regimes are among the most powerful engines for new settlements. Accordingly, the professions-state-public relationships must be understood as dynamic configurations that allow for various ways to model and remodel power relations in healthcare (Kuhlmann, 2006).
In summary, following governance theory we see the notion of “managerial state” (Clarke and Newman, 1997) as a changing concept of state power and seek to explore the specific nature of managerialist changes in healthcare, thus bringing into focus the “how” of the governance practices and their intersections with the formal institutions embodied in the healthcare state. As mentioned previously, we introduce an approach to healthcare states as “filters” of new governance practices. However, change in healthcare is clearly driven by various forces, which cannot be assessed by simply looking at the formal institutions and hierarchical forms of governing. In our analysis, therefore, we move beyond a mere institutionalist argument and suggest placing the “filtering” capacities of the healthcare state in a broader architecture of changing governance practices.
We introduce the state-profession relationship as another important “filter” for managerialist approaches on their way further down the road into in the organisation of healthcare and individual practices. This capacity of “filtering” the policy flows arising from new managerialist governance practices is closely linked, and based on, the role of professions as mediators between the government and the citizens. Health professions, particularly medicine, enjoy the highest levels of trust in society and furnish health policy makers with the authority of science and expert knowledge. Thus, managerial regimes and professional action are characterised by reflexivity of change.
Following governance theory, our analysis of managerial regimes in healthcare moves beyond the “either-or” and “from-to’ questions” – hierarchical governance or new managerialism, professional autonomy or performance management, user choice or expert power, and so on. First and foremost, we insist on the complexity of governance changes caused by managerial regimes and the significance of social, cultural and economic contexts. While arguing the need to resist the appeal of managerialism as a “one-size-fits-all” model of governing healthcare, we are nonetheless interested in exploring trends and effects of managerialism. Here, a comparative perspective on institutions – nation states and organisational settings – helps us arrive at a better understanding of “how” new health policies play out in different institutional contexts, taking into account provider and user perspectives. This is important given the prominence of a generic model of managerialism in healthcare and the discourse of convergence of health systems that is especially relevant in the European context.
3. Structure of the special issue
The collection of articles presented here brings together case studies of contemporary healthcare governance from European healthcare states and Canada. It includes both multiple and single country case studies. The individual contributions focus on organisational settlements/services and professional groups located at different ends of the healthcare system: the classic field of hospitals and specialised medical care on the one hand, and emerging fields of care services for the elderly and health promotion services for drug users provided by multi-professional teams on the other hand. The connecting link between the different organisational/professional fields and country specific contexts is the exploration of the contingencies and the dynamics of the new managerial governance in healthcare, more specifically the ways in which the architecture of healthcare states and the strategies of professions filter such changes in the governance of healthcare.
The first three papers explore how recent health reforms have affected the governance of medical services. In their study of the introduction of clinical guidelines in Britain and Germany Viola Burau and Laura Fenton focus on how sector specific institutions filter governance change. In this respect clinical guidelines are a critical case because they enjoy high international currency. With its cross-country comparative focus, this study identifies systematic variations across healthcare states and the specific ways in which they impact on the introduction of New Public Management. In Britain, clinical standards have taken the form of two parallel policies, which strengthen hierarchy-based governing and redefine professional self-regulation. In Germany, by contrast, clinical standards come in one single policy, which strengthens the hybrid of network and hierarchy-based governing and to some extent also pure hierarchy-based forms of governing. The analysis shows that institutions matter in relation to the framing of policy problems, the process of policy-making and the substance of policies, themselves.
In contrast, Anne Marije van Essen in her analysis of new hospital payment systems in the Netherlands, Germany and Britain looks at medical strategies and how they unfold in different institutional settings. The reforms introduce performance-based payment together with quality assessment and thus offer interesting insights into intersections between the medical profession and the state in the context of new managerial governance practices. The kinds of strategies used by the medical profession in relation to reform vary considerably. The Dutch corporate medical body was most willing to solve the conflict, while the German and English corporate medical bodies seem to be keen to use a strategy of confrontation. The differences in medical strategies also impact on the ways in which hospital payment systems have emerged in the three countries. The findings point to institutionally embedded differences related to the strength of competitive elements in the payment system itself as well as the involvement of the medical profession in the policy process. The study underlines the filtering capacity of both institutional settlements of the healthcare state and the medical profession.
Whereas these two contributions are concerned with the level of policy making, the study of changes in hospital governance in Belgium by Gregory Gourdin and Rita Schepers moves to the level of the hospital. This research attempts to explore current transformations in hospital governance by tracing the evolution of medical autonomy in the Belgian hospital sector in the second half of the twentieth century. Using a historical approach, the authors examine the extent to which organisations have the capability to manage change while retaining other objectives. The findings highlight the dialectical relations between institutions and medical strategies as filters of governance change. The evolution of new managerial practices points to the role in institutional reflexivity of the expert who delivers the material the institution needs for self-evaluation and for improving its functioning. Thus, doctors are becoming “managers of expertise” who are important for both the organisation and the healthcare state.
Patricia Khokher, Ivy Lynn Bourgeault and Ivan Sainsaulieu also look at hospitals but move the analysis towards the micro level of professional interactions and the new demands for collaborative care and teamwork approaches. The research explores changing organisational and professional relationships in hospitals, using developments in the Canadian healthcare system as a case study. A comparison of four different organisational settings of interdisciplinary teams helps to clarify if and how organisational culture impacts on the orientation of professionals working within teams. The findings highlight the significance of organisational settings and hospital management and call for a re-definition of professional boundary work as a main barrier towards innovation and collaboration. In this study the unit influences clearly outweighed the influences of professional boundaries on these health professionals when sources of satisfaction/dissatisfaction and issues of relationships with patients, co-workers and management were considered. The study offers insights into the diverse ways in which professions can feel affected by managerialism. The analysis highlights the importance of specific organisational contexts besides (macro level) differences in healthcare states. As such, it opens up the black box of the healthcare state and offers a more finely grained picture of the processes that occur when the healthcare state meets managerialism.
The remaining two contributions also include micro level interactions but move away from the organisational field of medical practice and explore more broadly how the relationships between professions, citizens/users and the state are reframed in the context of new managerial regimes. Mia Vabø looks at care services for the elderly and examines how retrenchments and realignments impact on the prevailing care work practice and policy in the context of the Nordic welfare state. This study offers interesting insights into how conflicts between the salient universalism and the new selectivism are playing out. It draws attention to competing demands caused by conflicting policy aims and administrative values. The findings highlight that reforms are infused with administrative arguments linked to previous reform ideas aiming to create legitimacy both from “above” and from “below”. In turn, this makes for the unintended and perverse consequences rather than a unidirectional and coherent reform strategy.
In their study of health prevention services for drug users Anna Leppo and Riikka Perälä examine another component of managerialism, namely the promises to offer a new empowered role to service users based on “choice” and “voice”. The study explores how choice is translated into day-to-day encounters between professionals and service users by comparing two organisational settings. The findings highlight that institutional context at the meso level and gender shape the everyday realisation of the new ideal of user choice. In both organisational settings, however, professionals have adopted new practices and rethought their role. The analysis reveals how professionals rethink and negotiate their role in a situation where there exists a tension between the new client-centred approach and more traditional approaches. The cultivation of service users’ choice and agency can become valuable professional capital, a new kind of “know how” that can also be used by the professionals to justify the importance of their work. Accordingly, this study underlines both the significance of institutional settlements (especially at meso level) and the capacity of professions to “filter” the managerial governance practices, thus creating “new settlements” of professional-user relationships.
The articles presented here highlight that new managerial regimes move far beyond organisational control of professions. Instead, managerial regimes initiate fundamental changes in the concept of “healthcare state” itself and the related modes of professionalism and citizenship/user rights. Certainly, changes in the governance of healthcare systems, and more specifically in the organisation and provision of healthcare, stretch far beyond the type of top-down filtering often described by institutional analysis. This should not, however, lead us to throw out the baby with the bath water. Instead, there is a need for more complex and context sensitive models that are capable of exploring the ongoing significance of the healthcare state and its formal institutions without assuming a linear pathway of change. Our approach on healthcare states as filters of managerial governance practices brings into perspective the changing concept of the state that continues to shape, but does not fully steer, strategic action of professionals and their agency in the governance process. Consequently, we need to look at the process of governing and the actors involved rather than simply asking for the outcomes of managerial regimes.
The filtering function of healthcare states, together with the capacity of professions to act as meso and micro level “filters” and even transform managerialism into strategic action, call for a critical refection of the search for a uniform model of governing healthcare systems. To this end, convergence of healthcare systems may not happen as easily as health policy makers assume. Also, it may not be the ultimate solution for the modernisation of healthcare systems and the transformation from supply to more demand-led services. We hope the results presented in this special issue encourage further empirical studies and theoretical investigations that help us understand the empowering conditions as well as the blockades of specific institutional settlements. This may also bring into view “new settlements” that host a wider potential for innovation than universal managerialist regimes.
The special issue mainly draws on selected contributions to sessions organised by the Research Network “Sociology of Professions” during the 8th Conference of the European Sociological Association in September 2007 in Glasgow, complemented by contributions based on working papers. The Guest Editors wish to thank the authors for their collaboration and a number of colleagues who supported this effort by carrying out reviews or giving otherwise helpful comments on their work, especially Judith Allsop, Haldor Byrkjeflot, Iain Crinson, Mike Denk, Elizabeth Ettorre, Peter Kragh Jespersen, Ruth McDonald, Hildegard Theobald, Willem Tousijn, Claus Wendt, Paul Williams, David Wilsford and Sirpa Wrede. They also would like to thank Robert H. Blank for his careful language editing. Finally, they wish to thank Nancy Harding as the Editor of the Journal of Health Organization and Management for supporting this special issue.
Ellen KuhlmannSenior Lecturer in the Department of Social and Policy Sciences, University of Bath, United Kingdom. She has been the coordinator of the Research Network “Sociology of Professions” of the European Sociological Association.
Viola BurauAssociate Professor in Public Policy in the Department of Political Science, University of Aarhus, Denmark. She is a member of the Board of the Research Network “Sociology of Professions” of the European Sociological Association.
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