Mike Dent

Medicine and management in a comparative perspective: the case of Denmark and England

In health systems around the world the current trend has been for doctors to increase their participation in management. This has been taken to imply a common process of re-stratification with new divisions emerging between medical elites and the rank and file. However, our understanding of this change remains limited and it is open to question just how far one can generalize. In this paper we investigate this matter drawing on path dependency theory and ideas from the sociology of professions. Focusing on public management reforms in the hospital sectors of two European countries - Denmark and England - we note similarities in the timing and objectives of reforms, but also differences in the response of the medical profession. While in both countries new hybrid clinical management roles have been created, this process has advanced much further and has been more strongly supported by the medical profession in Denmark than in England. These findings suggest that processes of re-stratification are more path dependent than is frequently acknowledged. They also highlight the importance of national institutions that have shaped professional development and differences in the way reforms have been implemented in each country for explaining variation.

Professionalism, educated labour and the state: hospital medicine and the new managerialism

This article examines the degree to which doctors, as members of an autonomous profession, function as organic intellectuals within capitalist society (Abercrombie and Urry, 1983) and, more generally, the complex and ambivalent relations that sustain their role within a ‘service class’. It is in this context that the organization of medical care and its delivery in Britain will be addressed. In particular, the current and intended changes in the organization and control of hospital medicine within the NHS, notably the issues of medical audit, clinical budgeting and the role of the ‘internal market’.

Patient choice and medicine in health care

Abstract The moves to greater patient choice within the UK, to the extent they have actually occurred, have begun to redefine the relations between the patient, professional and state. Rather than the doctors being the voice of the patients it is now the state administrations claim to have begun to provide patients with their own voice(s) and choices. Whereas traditionally the physician would claim to speak for the patient in order to demand more clinical resources now it is the management who demands, on behalf of patients, greater efficiency and effectiveness from the medical and health care staff. Cynically one might suggest that the policy is as much about disciplining the professionals as it is in providing real choice. The new public management (NPM) rhetoric has familiarized us to the notion of empowerment and the importation of consumerism and the ‘market’ to the public sector, a process that has begun to undermine our pre-existing assumptions of the autonomy of the professionalized elements of expert labour, including medicine, and the impact of NPM has meant their growing ‘responsibilization’ (Hanlon 1998; Fournier 1999, 2000). At least, that is a possibility.

The contested terrain of hospital management: Professional projects and healthcare reforms in Denmark

Although much has been written on the changing management of professional services organizations, only limited attention has been given to the way in which management itself might represent a contested terrain. Drawing on concepts from the sociology of professions, this article develops this idea in relation to the Danish hospital sector. The analysis of secondary sources reveals how, from the mid-1980s, both the nursing and medical professions in Denmark actively sought to lay claim to the jurisdiction of hospital management. The result of this struggle was to further reinforce the dominant position of doctors in the clinical division of labour although the position of nurses has also been enhanced. Such findings point to the need to give more attention to the way broader changes in hospital governance are mediated by interprofessional struggles and rivalries. Such struggles, in turn, have implications not only for the division of labour and status order between professions but also for the way management work itself is enacted. Même si beaucoup a été écrit sur la gestion en évolution des organisations professionnelles, seule une attention limitée a été portée à la façon dont la gestion elle-même peut représenter un champ contesté. À partir des travaux classiques de Freidson et d’Abbott, cet article développe ces idées dans le cadre de l’hôpital danois. L’analyse de sources secondaires révèle comment, à partir du milieu des années 80, les professions d’infirmiers tout comme les professions médicales au Danemark ont activement cherché à revendiquer le droit de gérer l’hôpital. Le résultat de cette lutte fut de renforcer encore la position dominante des médecins dans la division clinique du travail même si la place des infirmiers a été revalorisée. De tels résultats indiquent le besoin d’accorder plus d’attention à la façon dont des changements plus importants dans la gouvernance de l’hôpital font l’objet d’arbitrage par des rivalités et des luttes interprofessionnelles. Par ailleurs, de telles luttes, ont des conséquences non seulement sur la division du travail et le statut hiérarchique entre les professions, mais aussi sur la façon dont les tâches de gestion elles-mêmes sont effectuées. Aunque se ha escrito mucho sobre los cambios en la gestión de organizaciones de servicios profesionales, poca atención se ha dispensado, en cambio, a la manera en que la gestión en sí podría constituir un sector en disputa. A partir de los trabajos clásicos de Freidson y Abbott, este artículo desarrolla estas ideas en relación con el sector hospitalario danés. El análisis de fuentes secundarias muestra cómo, a partir de mediados de los 80, tanto las profesiones médicas como las de enfermería en Dinamarca buscaron activamente reivindicar la jurisdicción de gestión hospitalaria. El resultado de esta lucha fue la consolidación posterior de la posición dominante de los doctores en la división clínica aunque también mejoró la posición de las enfermeras. Tales conclusiones resaltan la necesidad de brindar mayor atención a la manera en que cambios más amplios en la dirección hospitalaria son mediados por luchas y rivalidades interprofesionales. Tales luchas, a su vez, tienen consecuencias no sólo para la división de trabajo y el estatus profesional entre profesiones sino también para el método en que la dirección en sí se lleva a cabo.

The Translation of Hospital Management Models in European Health Systems: A Framework for Comparison

In this paper we develop a framework for comparing changes in the management of public hospitals across different national health systems, drawing on insights from institutional theory. Using a range of secondary sources we show how one particular form of hospital management, pioneered originally at the Johns Hopkins Hospital in Baltimore, has been translated differently in four health systems: England, Denmark, Italy and France. This analysis builds on the notion of editing rules, which derive from the institutional context, and illustrates how these rules broaden our understanding of variable translations of global templates for hospital management. The paper concludes by highlighting wider implications for theory and policy.

Professional predicaments: comparing the professionalisation projects of German and Italian nurses

This article examines the similarities and differences in the professional and work organisation of nursing within two European countries: Italy and Germany. In principle both nursing systems could be expected to share much in common given they are both part of the European Community (EC). In practice the professional and work organisations are rather different. In Italy, the organised profession is currently being “promoted” from collegi to ordini, reflecting an upgrading of nurse education and training. Ordine (and collegi) are state‐sponsored mechanisms for professional registration, a system not to be found in Germany. Instead, German nurses through their professional organisations have been struggling to establish an autonomous role for themselves within the health service division of labour independent of the medical profession.

The development of medical‐manager roles in European hospital systems: a framework for comparison

A central motif of health reforms around the world has been the drive to persuade doctors and other clinical professionals to become more actively engaged in the management of services. Examples include moves to extend the commissioning role of primary care doctors (such as general practitioners in the UK) and the introduction of ‘clinical directorates’ in secondary care. This strategy has been seen as a means of controlling professionals, turning ‘poachers into game keepers’, especially with regard to resource allocation. However, there is also a mounting body of evidence pointing to how clinical leadership may play a role in stimulating quality improvement and new innovations inservice design, with positive consequences for patient safety and satisfaction (1). Focusing on the top 100 hospitals in the US Goodall (2) finds a strong positive association between the ranked quality of hospitals and whether the chief executive officer was a clinician. A survey of 1200 hospitals across seven countries (UK, US, Germany, France, Italy,Canada and Sweden) conducted by McKinsey and LSE also finds that clinically qualified managers improve both the effectiveness of management decisions and clinical performance of hospitals overall (3).

Disciplining the medical profession? Implications of patient choice for medical dominance

Abstract This paper deals with the dynamics of medical dominance and patient choice, primarily within the Britain, with reference to a range of other European countries too (including Germany, France and Greece) for comparative purposes. It will draw upon two concepts in particular: ‘responsibilisation’ and ‘protoprofessionalism’, the first undermining medical dominance the latter reinforcing it. The ongoing influence of a neo-liberal and managerialist agenda has eroded the certainties of the welfare state and the assumptions underpinning the dominant role of the medical profession, which has been subjected to increasing external state regulation and control (Dent 2003a). These reforms, which are associated with New Public Management, have been aimed at bringing the cost and quality of health care more effectively under the control of the state. This has involved redefining the compact or contract between the medical profession, public and the state. In this project greater emphasis is being formally given to the wishes of patients. Rather than the physician claiming to be the patient’s voice it is now the state administration’s assertion to have provided the patient with their own voice(s) - and choices.

Delivering patient choice in English acute hospital trusts

Abstract The role of the patient within the NHS has changed from supplicant to consumer to active participant. A demand-side patient-led approach is combining quasi-consumerism and participative democracy to inform and facilitate patient choice. On the supply-side funding and incentives coupled to reform and performance will deliver additional hospital capacity and patient choice. This paper argues from both a demand and supply-side perspective that there is a large gap between the rhetoric and reality of delivering patient choice in acute hospitals.

Medicine and management in European hospitals: a comparative overview

BackgroundSince the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context.Main textPrior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called ‘hybrid’ clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes.ConclusionsThe paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures.