Medicine and management in European healthcare systems: how do they matter in the control of clinical practice?

Medical hybridity and beyond: professional transitions in Italian outpatient settings

The marketization of public healthcare has brought about organizational transformations, affecting health professionals' ways of working in hospitals and outpatient organizations. As a result of the reforms in the 1990s, the principle of business-like healthcare has been introduced in the Italian health system. This paper presents the main findings of a study of specialist doctors working in two local health organizations in the Tuscany region. Drawing on semi-structured interviews with specialist doctors working in an outpatient setting, the article examines the manifold reactions to changes of the medical profession within outpatient settings. In particular, the combination of professional and organizational dimensions has been taken into consideration. The results show that a change is involving outpatient specialist doctors' identity: organizational change affects several dimensions of the medical professional ethos. The change has been understood by categorizing three major types of approaches to medical professionalism, which are aimed to understand the complexity of the domain and to summarize professionals' reactions: the first is linked to a traditional model of professionalism; the second accepts partially business-like organizational issues, while trying to create individual spaces of autonomy in daily tasks; the third co-opts new organizational issues, which become part of the medical professional ethos.

Políticas de saúde do Sul da Europa e desregulação das relações de trabalho: um olhar sobre Portugal

Resumo Sob o efeito do Memorando da Troika (2011-2015), as políticas de saúde em Portugal conhecem uma agenda política, empresarial e organizacional orientada por princípios de privatização, desregulação e subfinanciamento dos serviços públicos por parte do Estado. Neste artigo, faz-se uma revisão da literatura sobre os sistemas de saúde dos países do Sul, destacando-se a situação portuguesa quanto aos processos de reforma e principais desigualdades de saúde antes e durante a crise econômica. Complementarmente, convocam-se os testemunhos de diferentes profissionais do setor da saúde (médico, enfermeiro, técnico de terapêutica, sindicatos e dirigentes de unidades de cuidados). Baseado num estudo exploratório, discutem-se as transformações político-organizacionais e suas consequências na desregulação e precarização das relações de trabalho no setor da saúde. Reduções salariais, congelamento de carreira, instabilidade contratual, desmotivação profissional, intensificação do ritmo de trabalho e desqualificação dos serviços são alguns dos sinais mais visíveis de uma agenda gestionária que conflitua com as missões de um Sistema de Saúde Pública (SNS) universal ao serviço da sociedade portuguesa.

Dynamics between doctors and managers in the Italian National Health Care System

This article focuses on the changes in the Italian NHS by concentrating on patterns in the managerialisation of doctors. It addresses a series of shortcomings in studies on the response by doctors to managerialisation. The first is a shortcoming of theoretical and analytical nature. It is necessary to adopt a broader perspective whereby analysis considers not only the interaction between doctors and managers, but also the public control and regulation agencies that operate in that field. The second shortcoming is a methodological one. The literature on managerialisation is more theoretical than applied. It is necessary to adopt a strategy based on a plurality of methodologies and sources in order to focus attention on a national case (Italy in the present study), discussing the changes over time (from the beginning of managerialisation until today) and considering different groups within the medical profession. The outcome is a complex picture of the dynamics between doctors and managers which foregrounds the managerial co-optation processes of a small group of national health service doctors, the transition from strategic adaptation to forms of resistance against managerialisation by the majority of Italian NHS doctors, and the emergence of restratification processes among self-employed doctors working with the NHS.

Healthcare managers' construction of the manager role in relation to the medical profession

Purpose - The purpose of this paper is to explore how healthcare managers construct the manager role in relation to the medical profession in their organisations. Design/methodology/approach - In total, 18 of Sweden's 20 healthcare chief executive officers (CEOs) and 20 clinical department managers (CDMs) were interviewed about their views on management of physicians. Interviews were performed in the context of one aspect of healthcare management; i.e., management of physicians' sickness certification practice. A discourse analysis approach was used for data analysis. Findings - Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse dominated and managers frequently used the attributes "physician" or "non-physician" to categorise themselves or other managers in their managerial roles. Some managers, both CEOs and CDMs, shifted between the management- and profession-based discourses, resulting in a kind of "yes, but […]" approach to management in the organisations. The dominating profession-based discourse served to reproduce the power and status of physicians within the organisation, thereby rendering the manager role weaker than the medical profession for both physician and non-physician managers. Research limitations/implications - Further studies are needed to explore the impact of gender, managerial level, and basic profession on how managers construct the manager role in relation to physicians. Practical implications - The results suggest that there is a need to address the organisational conditions for managers' role taking in healthcare organisations. Originality/value - Despite the general strengthening of the manager position in healthcare through political reforms during the last decades, this study shows that a profession-based discourse clearly dominated in how the managers constructed the manager role in relation to the medical profession on the workplace level in their organisations.

Professionals' perspectives on a market-inspired policy reform: A guiding light to the blind spots of measurement

Implementation of market-inspired competition and incentive models in health care is increasing worldwide, assumed to drive efficiency. However, the evidence for effects is mixed and unintended consequences have been reported. There is a need to better understand the practical consequences of such reforms. The aim of the present case study is to explore what consequences of a Swedish market-inspired patient choice reform professionals identify as relevant, and why. The study was designed as an explorative qualitative study in specialized orthopedics. Nineteen interviews were conducted with health care professionals at different providers. Data were analyzed using a hypo-deductive thematic approach. Consequences for the organization of care, patients, work environment, education and research were included in the professionals' analyses, covering both the perspective of their own organization and that of the health care system as a whole. In sum, the professionals provided multiple-level analyses that extended beyond the responsibilities of their own organization. Concluding, professionals are a valuable source of knowledge when evaluating policy reforms. Their analyses can contribute by covering a broad system perspective, serving as a guiding light to areas beyond the most obvious evaluation measures that should be included in more formal evaluations.

Understanding physicians' professional knowledge and practice in research on skilled migration

Research on the integration of migrant professionals into high-skilled labor markets either focuses on differences between nation states which may be exacerbated by national closure or it celebrates the global versatility of professional knowledge, especially in the natural and health sciences. Building on a pragmatist approach to professional knowledge, the article argues that professional knowledge should not be seen as either universal or local, but both the institutionalized and the incorporated aspects of cultural capital are characterized by 'local universality'. Professionals recreate professional knowledge in specific 'local' situations by relating to universal standards and to internalized 'libraries' of situated expert experience. While the more common notion of knowledge as a socially contested resource continues to be relevant for research on skilled migration, professional knowledge should also be seen as emerging in situations in response to socio-material problems. These problems can be structured by the nation-state, but they can also be transnational in nature.

Medicine and management: looking inside the box of changing hospital governance

Background

Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing ‘hybridization’ of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study.

Methods

We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the ‘managed’ and the ‘managing’ doctors in an organization.

Results

Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial–professional coordination at the micro-level of the organization.

Conclusion

This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management.

Physician' entrepreneurship explained: a case study of intra-organizational dynamics in Dutch hospitals and specialty clinics

BACKGROUND

Challenges brought about by developments such as continuing market reforms and budget reductions have strained the relation between managers and physicians in hospitals. By applying neo-institutional theory, we research how intra-organizational dynamics between physicians and managers induce physicians to become entrepreneurs by starting a specialty clinic. In addition, we determine the nature of this change by analyzing the intra-organizational dynamics in both hospitals and clinics.

METHODS

For our research, we interviewed a total of fifteen physicians and eight managers in four hospitals and twelve physicians and seven managers in twelve specialty clinics.

RESULTS

We found evidence that in becoming entrepreneurs, physicians are influenced by intra-organizational dynamics, including power dependence, interest dissatisfaction, and value commitments, between physicians and managers as well as among physicians' groups. The precise motivation for starting a new clinic can vary depending on the medical or business logic in which the entrepreneurs are embedded, but also the presence of an entrepreneurial nature or nurture. Finally we found that the entrepreneurial process of starting a specialty clinic is a process of sedimented change or hybridized professionalism in which elements of the business logic are added to the existing logic of medical professionalism, leading to a hybrid logic.

CONCLUSIONS

These findings have implications for policy at both the national and hospital level. Shared ownership and aligned incentives may provide the additional cement in which the developing entrepreneurial values are 'glued' to the central medical logic.

Mobilising identities: the shape and reality of middle and junior managers’ working lives – a qualitative study

Background

Social identities shape how individuals perceive their roles and perform their work. Yet little is known about the identities of various types of NHS managers and even less about how they may influence how they carry out their work to achieve effectiveness.

Objectives

To chart the work of middle and junior clinical and non-clinical managers; to describe how their identities are constructed and shape the performance of their roles; to explore how they mobilise their identities to achieve effectiveness.

Design

Qualitative research.

Setting

Two large English hospital trusts.

Participants

Data consisted of 91 semistructured interviews with four primary categories of managers [junior clinical (JC), junior non-clinical (JNC), middle clinical (MC), and middle non-clinical (MNC)], shadowing of a small subsample, observations of meetings. For some analyses the four categories were broken down into finer-grained ‘work groups’. The data were analysed both qualitatively, using the constant comparative method, and quantitatively, using the method of ‘quantitising’ (the numerical translation of qualitative data).

Results

Respondents’ identitiesas managerswere not particularly strong. Results reveal a more nuanced and widely spread portrait of the ‘reluctant manager’ than hitherto reported. The picture ofwhat managers dowas complex and multifaceted. On some dimensions, such as ‘span of responsibility’, ‘span of control’ and cross-site working, internal variations by ‘work group’ indicate that comparisons between the four primary categories were not particularly meaningful. Variety was added to by internal diversity even within ‘work groups’. Analyses ofself-reported effectivenessrevealed that ‘hard’, demonstrable measures of performance (‘transactional effectiveness’) were important to all four categories of managers; however, many were also concerned with ‘softer’ indicators involving enabling, supporting and developing a team (‘processual effectiveness’). Many felt ‘processual effectiveness’ fed ‘transactional effectiveness’. It was also regarded as a form of effectiveness in its own right that could be compromised by undue attention to ‘transactional effectiveness’. Across all categories respondentsmobilisedbothmanagerial identitiesand ‘other’ professional identities (e.g. nurse, doctor, accountant or scientist) for effectiveness. Although mobilisation capacities of ‘other’ identities were fairly explicit,managerialidentity often appeared ‘in disguise’. There was a tendency to refer to experience or tenure within the organisation as a resource to influence others and to cite ability to communicate as their personality trait, yet this implies skilled knowledge of organisational context. Equally, identifying, for example as a ‘people person’, encompasses a raft of management skills such as the ability to translate specific demands placed on their subordinates by the organisation in terms that are clear and meaningful. The research also revealed that the ‘mobilising capacities’ of the ‘facets of identity’ of the various ‘work groups’ were subject to identity constraints arising from others ‘above’, ‘below’ and ‘laterally’, as well as from the wider organisation (such as culture, resources) and their workload. For clinical managers, it was also constricted by juggling clinical and non-clinical work within time constraints.

Conclusions

Many respondents struggled with their identities as managers. Given that a strong identity is associated with uncertainty reduction and employee strengthening, more work is needed to improve how positive identities can be fostered both among managers themselves and amongst those with whom they interact. To fully comprehend the relationship between self-perceived identities and how managers carry out their work it is recommended that future research gives attention not only to variation across but also within primary categories and work groups.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Measuring clinical management by physicians and nurses in European hospitals: development and validation of two scales

Objective

Clinical management is hypothesized to be critical for hospital management and hospital performance. The aims of this study were to develop and validate professional involvement scales for measuring the level of clinical management by physicians and nurses in European hospitals.

Design

Testing of validity and reliability of scales derived from a questionnaire of 21 items was developed on the basis of a previous study and expert opinion and administered in a cross-sectional seven-country research project ‘Deepening our Understanding of Quality improvement in Europe’ (DUQuE).

Setting and Participants

A sample of 3386 leading physicians and nurses working in 188 hospitals located in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.

Main Outcome Measures

Validity and reliability of professional involvement scales and subscales.

Results

Psychometric analysis yielded four subscales for leading physicians: (i) Administration and budgeting, (ii) Managing medical practice, (iii) Strategic management and (iv) Managing nursing practice. Only the first three factors applied well to the nurses. Cronbach's alpha for internal consistency ranged from 0.74 to 0.86 for the physicians, and from 0.61 to 0.81 for the nurses. Except for the 0.74 correlation between ‘Administration and budgeting’ and ‘Managing medical practice’ among physicians, all inter-scale correlations were <0.70 (range 0.43–0.61). Under testing for construct validity, the subscales were positively correlated with ‘formal management roles’ of physicians and nurses.

Conclusions

The professional involvement scales appear to yield reliable and valid data in European hospital settings, but the scale ‘Managing medical practice’ for nurses needs further exploration. The measurement instrument can be used for international research on clinical management.

"A manager in the minds of doctors:" a comparison of new modes of control in European hospitals

Background

Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals.

Methods

The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources.

Results

The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management.

Conclusions

Our comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.

Health care management of sickness certification tasks: results from two surveys to physicians

BACKGROUND

Health care in general and physicians in particular, play an important role in patients' sickness certification processes. However, a lack of management within health care regarding how sickness certification is carried out has been identified in Sweden. A variety of interventions to increase the quality of sickness certification were introduced by the government and County Councils. Some of these measures were specifically aimed at strengthening health care management of sickness certification; e.g. policy making and management support. The aim was to describe to what extent physicians in different medical specialties had access to a joint policy regarding sickness certification in their clinical settings and experienced management support in carrying out sickness certification.

METHOD

A descriptive study, based on data from two cross-sectional questionnaires sent to all physicians in the Stockholm County regarding their sickness certification practice. Criteria for inclusion in this study were working in a clinical setting, being a board-certified specialist, <65 years of age, and having sickness certification consultations at least a few times a year. These criteria were met by 2497 physicians in 2004 and 2204 physicians in 2008. Proportions were calculated regarding access to policy and management support, stratified according to medical specialty.

RESULTS

The proportions of physicians working in clinical settings with a well-established policy regarding sickness certification were generally low both in 2004 and 2008, but varied greatly between different types of medical specialties (from 6.1% to 46.9%). Also, reports of access to substantial management support regarding sickness certification varied greatly between medical specialties (from 10.5% to 48.8%). More than one third of the physicians reported having no such management support.

CONCLUSIONS

Most physicians did not work in a clinical setting with a well-established policy on sickness certification tasks, nor did they experience substantial support from their manager. The results indicate a need of strengthening health care management of sickness certification tasks in order to better support physicians in these tasks.