Liisa Kurunmäki

A hybrid profession¿the acquisition of management accounting expertise by medical professionals

This paper argues that medical expertise in Finland was “hybridised” in the first half of the 1990s. It examines the willing adoption of management accounting techniques by medical professionals in the context of the New Public Management reforms in Finland. It documents this process of adoption, charts some of its effects for the set of practices and legitimated competencies that make up the domain of medical expertise, and seeks to understand these by reference to the position of management accounting within the Finnish pedagogic and institutional setting. As a counterpoint, it notes the contrast with the UK, where medical professionals have been seen to resist the intrusion of accounting practices into the medical domain.

Professional vs financial capital in the field of health care—struggles for the redistribution of power and control

Abstract The field of health care, like all fields of social life, is a site of continuous games for power and control. This paper applies the conceptual tools of the French sociologist Pierre Bourdieu—in particular the notions of field and capital—to analyse the diverse roles, and partially divergent objectives of the various institutions and individuals involved in the functions of financing, production, and consumption of health services. Participants in these struggles are seen to have different chances of winning or losing, depending on their relative power, which is determined by the distribution of differently valued capitals in this specific field. The expectations associated with the transition to market based control mechanisms in the field of Finnish health care, and the experiences of those directly involved in this transition are analysed. The nature and implications of the process of transition from a planning allocation system to a competition based resource allocation system are studied on the basis of extensive interviews and observations conducted in one university hospital and two central hospitals in Finland.

Accountingization v. Legitimation: A Comparative Study of the Use of Accounting Information in Intensive Care

Abstract This is a comparative study of management accounting in intensive care units in the UK and Finland. The management accounting problems of health care in many countries are well documented in the literature (difficulties of budgetary implementation: non-integration of health care professionals into the financial management process). This study examines these issues in the situation of intensive care, where there are difficult ethical decisions to be made by health care professionals in a climate of rapid medical advance where financial constraints may lead to rationing of health care. This paper reveals commonalities between these two countries in terms of intensive care problems, but there are differences, too, which can be attributed to contrasts in management accounting practices in the two countries.

Modernising Government: The Calculating Self, Hybridisation and Performance Measurement

No abstract available.

Making an accounting entity: the case of the hospital in Finnish health care reforms

This paper is about the making of an accounting entity. The entity is the hospital, and the context is the Finnish health care reforms of the early 1990s. These reforms, which sought to make private sector accounting principles central to this core field of the New Public Sector, had significant implications for the varied actors involved in the financing, production and consumption of health care. For the defining of the hospital as an accounting entity entailed a narrowing of the basis of accountability, and to this extent it came into conflict with the broader societal conceptions of accountability held by medical professionals. This narrowing of the basis of accountability, and the attempt to ensure that decisions concerning resource allocation and equipment purchase are similarly focused, is examined in this paper along with the reaction of medical professionals. Accounting is possible only when there is an area of economic interest that can be defined. Indeed, this is the essence of the entity concept in accounting. When a definable area of economic interest exists, it is possible to identify, accumulate, and report financial information about that entity as distinct from all other information. Without such an entity, accounting is impossible. (American Accounting Association, 1965)

Calculating failure: The making of a calculative infrastructure for forgiving and forecasting failure

This paper examines how the category of failure was economised and made calculable. It explores the preconditions for this shift in three stages. First, it explores how failure came to be ‘forgiven’ in both the US and the UK across the nineteenth century, how it came to be defined as something that is economic or financial, rather than personal or moral. Second, it explores the rapid growth of narrating and rating failure in the mid-nineteenth century, with particular attention to the formation of credit rating agencies from the 1840s onwards. We consider also the roles played in this process by two fortuitous technological developments: the typewriter and carbon paper for copying. Third, we examine the emergence of the calculative infrastructure, which has helped to establish an industry of attempts to forecast failure from the beginning of the twentieth century, initially on the basis of financial ratios, and more recently through the use of risk indexes. We use the term ‘calculating failure’ to describe this transformation and economisation of both the ideas and the instruments of failure, and suggest that this has significant implications for the study of strategy.

Management Accounting, Economic Reasoning and the New Public Management Reforms

Abstract New forms of accounting and new forms of accountability have emerged out of the set of reforms that are often referred to as “New Public Management.” These changes, which are transnational even if they are not yet global, have had an impact on actors in a diverse range of settings including education, culture, policing, probation, prosecution, healthcare, social services, transport and defence. A substantial body of literature on accounting in its social and institutional context has analyzed how accounting practices affect the ways in which organizations, and the various actors that populate them and their environment, define and shape the choices available to them. It has examined how the use of accounting tools and technologies shape the ways in which activities and processes come to be articulated, debated and made operable. Accounting has been seen to possess significant potential for changing the exercise and balance of power within organizations. The roles of accounting expertise in these changes have been discussed, as has the willingness of other experts and professionals to acknowledge the influence of accounting and accountants. This chapter, which focuses on a set of studies that have analyzed the ways in which accounting has contributed to a reshaping of existing power relations in various public sector settings, touches on three separate yet overlapping literatures: first, the relevant literature that has examined accounting in its social and institutional context, both in the public and private sector settings; secondly, the body of research on the accounting aspects of new public management reforms, including studies that go beyond the Anglo-American contexts and that focus in particular on the capacity of accounting to shift power relations in a range of public sector settings; thirdly, sociological studies of professions and professional expertise, for at the heart of the new public management reforms is not only an encounter between different types of practice, but an encounter between formally distinct and often competing professional groupings. Having reviewed briefly these three sets of literatures, this chapter considers in more detail a small number of studies that examine the shift from “financial literacy” to “hybridization,” a shift that is suggested to be a central aspect of the encounter between management accounting, economic reasoning and the new public management reforms.

Counting the costs: The risks of regulating and accounting for health care provision

Abstract Payment by Results (PbR) is one of the most fundamental changes in NHS policy since the introduction of the ‘internal market’ in 1991. It is also one of the most visible and influential attempts across the same period to modernize the NHS through accounting and, more specifically, costing. As a funding system, PbR promises to pay providers fairly and transparently by using a ‘standard national tariff.’ However, like all accounting based reforms, PbR encounters the range of professions and expertises active in the domain. Like all costing systems that give visibility where previously it was lacking, PbR creates new calculable spaces and new risks. The aim of the paper is threefold. First, we seek to chart the nature of the arena within which PbR operates. We identify the multiple actors that are influential in the regulatory field of health service provision, and focus on three types of actor in particular, namely the National Institute for Health and Clinical Excellence (NICE), Monitor and professional medical associations. We argue that these three actors need to be viewed as representative of different types of expertise (schematically speaking, health economics, accounting and medicine) and that, to understand fully the nature of the regulatory game in the healthcare arena, PbR needs to be analysed not as a stand alone intervention but as enmeshed within the inter-professional complex that emerges out of the interaction of these three types of expertise. Second, we argue that we need to focus on the ways in which PbR, along with other regulatory interventions in the healthcare field, such as those of NICE and Monitor, seek to create new and sometimes competing calculable spaces based on different entity assumptions. Third, we argue that to understand empirically the dynamics of healthcare reform in the UK we need to examine the extent to which PbR creates new calculating selves, or a hybridizing of the calculating and medical self. The regulatory complex within which PbR operates may, we argue, produce contradictory incentives and thereby contribute to systemic provision risks.