Peter Kragh Jespersen

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.

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.

PROFESSIONS, INSTITUTIONAL DYNAMICS, AND NEW PUBLIC MANAGEMENT IN THE DANISH HOSPITAL FIELD

ABSTRACT This article elucidates the role of professionals as stakeholders in the Danish hospital field. The sociological new-institutionalism has illuminated the role of professions as carriers of rationalities and norms and their role in radical changes in organizational fields, but we are short of contributions that elucidate their role as stakeholders in connection with incremental changes in mature organizational fields. First we focus on what interests professions can be expected to safeguard. We will argue that professions protect and expand their professional rationalities. In mature fields this must be done in interaction with the state apparatus that in numerous ways regulates the professions. Second we assume that in mature organizational fields, dominated by professional interpretative schemes, the professions’ safeguarding of interests will be tied to their influence on the creation of new institutions within the existing institutional landscape in the field. More specifically we argue that the professions’ opportunities of influence depend on: The existing constellationof institutions in the field. The degree of competitionamong new and old institutions. The existing political-administrative structure. The power relationsbetween actors in the field. Our empirical cases concern two attempts of institutional innovation in the Danish hospital field. In this field, attempts are made during the 1980s and the 1990s to introduce a series of innovations inspired by the New Public Management (NPM) strategy. We have examined two such innovations: Unambiguous managementand systematic quality development. The professionals have been able to maintain the dominant professional interpretive schema through a combination of central and local safeguarding of interests that has barred the two NPM inspired innovations from being disseminated effectively into the field. Another reason why the NPM strategy does not seem to have great impact in the two cases is, we think, that a coherent strategy was never formulated in Denmark. The two case analyses support our assumptions and are not conflicting with the conclusions of others on radical changes in organizational fields.1-4 We conclude that the four factors contribute to explain the success of the professionals. They might also be useful as general factors explaining the influence of the professions on the field dynamics and institutionalization in mature organizational fields. Another conclusion is that we should be very careful to generalize about the influence of the professionals from one country to another. Even if professional rationalities were alike, the institutional constellation and competition, the administrative structures and power relations differ strongly from one country to another. This might explain the different outcomes of NPM strategies in profession dominated fields in various countries.

Three conceptualizations of hybrid management in hospitals

Purpose – The purpose of this paper is to bring the discussion on the relationship between management and medicine a step forward by focussing on: first, how the notion of hybrid and hybridity has been used in the literature on healthcare management. Second, the authors have mapped the alternative ways that the concept have been used in order to conceptualize a more specific set of possible combinations of managerial and professional roles in healthcare management. Hybrid management is a topic that ought to be important for training, communication among researchers and for identifying areas of future research: in management, in healthcare reforms, in sociology of professions and in theory of organizations. Design/methodology/approach – The authors provide a systematic literature review in order to map the various conceptualizations of hybrid management. The authors have searched for “hybrid leadership,” “hybrid management” combined with hospitals and health care in a whole range of journals, identified in...

Quality development and professional autonomy in modern hospital fields

In modern societies, universities have flourished as central public institutions. Higher education and research became overwhelmingly a public responsibility and universities were perceived as contributing to the public good. Universities were heavily subsidized by governments, publicly provided by employees of the state, and closely regulated in respect to curriculum, teaching and research staff, infrastructural facilities, and achievement standards. In historical terms this is a recent phenomenon in which the development of a public mandate in higher education and research took the form of establishing publicly controlled, state-funded, state-owned institutions. Certainly, the well-established tradition of direct, extensive public responsibility for elementary and secondary education had created an important precedent for public involvement in higher levels of education. The public role of universities was reinforced by the prominent role that higher education played in building nation-states and their public sectors. Further, the emergence of the research university linked the research function to the educational one bringing science and technology into the public realm. The ‘publicness’ of universities, including the important role of government responsibility, oversight, and funding, the legal status of the organizational providers and their staff, is not only a recent phenomenon, viewed historically, but is currently being challenged in many ways. We currently observe that traditional boundaries and understandings of the public and private spheres in higher education have become blurred, in a similar way to other sectors of society that were previously under tight public control. This can be seen, among other things, in the delegation of public policy to semi-public organizations, non-governmental, arm’s-length agencies, independent regulatory bodies or public–private policy networks. It also relates to a process by which elements of the fabric of higher education and research are withdrawn from the public sphere, with universities setting up private companies, outsourcing research, teaching or support services, and the emergence of public–private partnerships or new private organizations. The opposite is also observed: the introduction of elements of the private sphere into the public realm of the university. Examples involve the state-induced enforcement of competition, the increasing 1111 2 3 4 5111 6 7 8 9 1011 1 2 3111 4 5 6 7 8 9 20111 1 2 3 4 5111 6 7 8 9 30111 1 2 3 4 5 6 7 8 9 40111 1 2 3 44 45111 5704 LEADERSHIP A-rev_156x234 mm 17/02/2012 06:52 Page 195