Hospital governance in European countries increasingly builds on mixed forms of governing and combines management and professional self-governance, thereby creating new more ‘hybrid’ controls that are expected to improve cost-efficiency and quality of services [
1]. Currently, much of the research is concerned with the instruments of governance, often assuming linear relationships between a new policy, its implementation and the effects in practice. But overall, new policies aiming at medical management do not deliver the desired results when implemented in practice. Conry et al. [
2] therefore conclude from their systematic review of hospital interventions that more theory driven interventions are needed in order to improve effective implementation. Here, our comparative study comes in and may help us to explore the determinants of new emergent forms of control.
In our study, we draw on a broad definition of ‘control’ (or ‘clinical management’ more generally) that includes a wide range of bureaucratic measurements and managerial tools, such as target setting and performance indicators, and also interventions where doctors have oversight, such as evidence-based guidelines and continuing professional development (CPD). The new emergent modes of control on the level of organisations are mapped in a cross-country comparative perspective, focusing on doctors as the target group of hospital governance and on costs and quality as the key areas of managing medical performance.
The linkage between macro-level (countries) and meso-level (organisations) governance through the lens of country comparison is innovative for two reasons: firstly, this makes it possible to move beyond a discourse of ‘hybridisation’ of medicine and management and to analyse
how the context matters and secondly, how this creates specific forms of control. This approach may contribute to a ‘deepening’ of our understanding of complex interventions into clinical management [
3] and explore new directions for cost-efficient and quality-effective hospital governance.
The concept of governance (as defined in the health policy debate and governance literature) [
4‐
8] may serve as a helpful framework in which to re-locate theories and research from the realms of the sociology of professions and organisations as well as management studies. Placed in a broader policy context, we revise the managerialism-professionalism relationships and introduce a more flexible and integrative approach. Empirically, we set the focus on processes and actors and contribute new material on how to improve operational governance in hospitals [
7] and control modes [
9] in a range of European countries. Methodologically, we bring cross-country comparison to the meso-level of the organisation in a range of European countries. This brings a novel perspective into comparative research, because comparison traditionally focuses on institutions on the macro-level and often uses Anglo-American countries and/or National Health Service (NHS) systems as examples [
10].
The empirical background: opening the box of control in hospitals
Over recent years, new managerial regimes were introduced that subsequently provoked scholarly debate about the outcomes, specifically in relation to the role of doctors and professionalism, and whether the changes may bring about risks or benefits for healthcare services and for patients [
11‐
17]. Yet, the evidence is scattered and controversial when it comes to the processes and organisational settings that create new modes of controls.
For example, a study carried out in the United States compares the leadership potential of doctors and managers using the quality of services provided in different hospitals as an indicator [
18]. This study clearly confirms that doctors take over management positions, but the evidence related to the leadership potential is far from clear. An increase in managerial governance is also confirmed by Reich [
19] who draws on electronic patient records and qualitative research from the US. According to this author, the new patient records are a ‘disciplinary technology’ that creates ‘disciplined doctors’ [
19], p. 1021. In a similar vein, Dixon-Woods et al. [
20] discuss new managerial governance tools as a threat to doctors and a kind of negative sanction to be applied if doctors are not able and willing to establish more effective self-governing control, as highlighted by the scandals in the National Health Service (NHS) in England.
Studies carried out in a range of European countries reveal variation in the transformations of control, thus drawing a more complex picture. To begin with, in the German medical profession, managerial and professional self-governing procedures are increasingly combined [
21]. These developments nurture the ‘rise of a new professionalism’ that may be more inclusive [21], p. 221, Table 10.11 but it also may embody opportunities for doctors to transform and strategically use managerial tools, like evidence-based clinical guidelines and quality reports. Some specialties are better equipped than others to utilise and integrate the new clinical management in daily professional practices. Consequently, the governance changes may also impact in the occupational structure and rearrange the order and status of professional groups [
21].
In a similar vein, but arguing from a Spanish perspective, Sacristán et al. [
22] highlight new connections between medicine and management that, in turn, provide new chances for doctors to utilise management. As the authors put it: ‘The evolution of the discipline and the trend towards a tailored therapy suggest that health economics is not the end of clinical freedom but the start of it’ [
22], p. 1; see also [
23]. Tousijn [
24], p. 529. in an Italian case study, also found that doctors ‘create their own managerial procedures’ rather ‘adapting’ or ‘modifying’ existing managerial procedures or ‘circumventing them’.
Drawing on material from Norway, Martinussen and Magnussen [
17] add further evidence of variety of transformations underway in healthcare. The authors conclude: ‘Our findings support the view that, rather than managerialist values colonising the medical profession through a process of hybridisation, there is heterogeneity within the profession: some physician managers are adopting management values and tools, whereas others remain alienated from them’ [
17,
25,
26]. A similar conclusion was drawn from a literature research of entrepreneurship in western hospitals. The authors identify ‘various responses’, including among others, a ‘transformative attitude towards traditional medical professionalism’ that supports entrepreneurial elements of healthcare [
27,
28].
A European study confirms a general trend towards new connections between management and professional self-governance that was described in single-country research or secondary analysis and adds further empirical evidence [
9]. This study highlights that, ‘medicine and management are “twin forces”, and as such indicative for the new emergent controls’ [
9], p. 722. What matters are the balance and the ‘specific composition of the toolset of controls’ [
9], p. 723. Here, it seems to be important to take the different levels of governance into account, because ‘publicly operated hospitals increasingly have a meso-level governance structure that resembles that of a private company’ and important decisions are increasingly made on this level [
7], p. 5.
In summary, existing research highlights important changes in the modes of control, but no uniform pattern of professionalism-managerialism relationships could be identified. Instead, there is growing evidence of variety, diversity and heterogeneity of the ways management and professionalism are connected, including the design of clinical management by doctors. This raises the questions what actually matters in creating new modes of control, and what are the determinants that may foster more efficient and integrated forms. Against the backdrop of a lack of any clear empirical evidence of favourable conditions and the call for more theory-led intervention strategy [
2], the next section critically discusses how the scholarly theories may support our research questions.
The theoretical background: the managerialism-professionalism relationship revisited
The US sociologist Eliot Freidson [
29] is perhaps the most prominent author who theorised the relationship between doctors/professionalism and management/bureaucratic regulations from the perspective of the sociology of professions. Freidson has argued that professionalism acts as a ‘third logic’ next to rational-legal bureaucracy developed by Max Weber, which represents managerialism, and ‘Adam’s model of the free market which represents consumerism’ [
29], p. 179.
The idea of a third logic is closely linked with the assumption of ‘countervailing powers’ and ‘conflict’ between professionalism and managerialism [
30,
31]. Although these approaches were most influential in the 1990s, they are still stressed especially in Anglo-American research. For instance, in their recent study of the medical profession in England, Dixon-Woods et al. argue: ‘The new rebalancing of the “countervailing powers” has dislodged the profession as the senior partner in the regulation of doctors, but may introduce new risk’ [
20], p. 1452.
The countervailing powers approach embodies the problems of dichotomy that cannot adequately grasp more inclusive and mixed emergent models and that underestimates the transformative capacities of professionalism [
8,
28]. Johnson [
32] was among the first who proposed to overcome the static and contradictory conception of external regulation and professionalism by taking up the Foucaudian concept of governmentality. This approach opens up new perspectives directing our attention toward social contexts and transformativity of professionalism. It also has paved the way for conceptualising medical self-regulation as one part of a complex set of governance [
9,
26,
33‐
35], and consequently, for more dynamic and reflective approaches.
Various authors from diverse (northern and continental European) countries have highlighted important changes underway in healthcare that create new forms of professionalism in order to better fit contemporary healthcare needs, as discussed, for instance, by Plochg et al. [
35], and also in relation to empirical findings mentioned in the previous section. Such new forms have been described variably as: ‘hybridisation’ [
36], p. 761 or ‘organized professionalism…calling for multi-professional acts’ [
37], p. 1360. ‘diversity of professionalism’ and flexibility between exclusionary and more ‘inclusive’ patterns [
21], p. 221; ‘compatibility’ of different modes [
28], p. 634 and ‘community professionalism’, as suggested by Tousijn [
24], p. 533 with reference to Adler et al. [
38]. Although the ‘labels’ differ, these approaches make much the same plea for overcoming the managerialism-professionalism dichotomy.
A static conception of the professionalism-managerialism relationship has also been questioned in organisational research [
39‐
41]. Here, one important focus is on the ‘blurring of boundaries’ between professionalism, conceptualised as ‘internal’ mode of governing, and managerialism as an ‘external’ governance approach attempting to improve control and transparency of elitist professional knowledge. Waring and Currie [
42], in their study of the management of knowledge around clinical risks in the NHS in the United Kingdom suggest ‘that doctors respond to change through a number of situated responses that limit managerial control over knowledge and reinforce claims to medical autonomy’ [
42], p. 755. The authors use three categories to describe doctors’ responses: ‘co-optation’, ‘adaptation’ and ‘circumvention’. The findings reveal how ‘management techniques are co-opted into professional work as a form of resistance, with professionals being competent in management practice, rather than being co-opted into management roles’ [
42], p. 774.
Cross-country comparative research has added strong evidence of the variety of changing professionalism-managerialism relationships. For example, Kirkpatrick and colleagues [
16], in their comparison of medicine and management in England and Denmark, highlight the ways through which national institutions have shaped professional development and ‘that processes of re-stratification are more path dependent than is frequently acknowledged’ [
6,
16,
33,
34].
The merging processes between management and medicine have primarily been studied from the perspective of doctors and changing modes of professionalism, but the contemporary transformations do not travel on a ‘one-way road’ from management to medicine [
12,
15,
43]. Von Knorring et al. [
44], in their qualitative study of Swedish top managers, have revealed that top managers in healthcare tend to remake existing hierarchies between doctors and managers. In this study, the country council chief executive officers often perceived the management role in their organisations as weak. The authors could not identify a clear strategy of managing doctors but, instead, revealed four different strategies, and concluded that this pragmatic behaviour may in a longer perspective lead to a decrease in ‘the legitimacy of the manager role’ [
44], p. 1. One important explanation for the persisting hierarchies might be the fact that managers cannot refer to a formalised knowledge system in the same way as doctors do [
8,
45].
In summary, the review of the literature reveals that ‘ownership’ of managerial tools is not naturally attached to management and managers, but can be used flexibly by different groups. Most importantly, there is no one uniform pattern of transformations and not ‘a’ new professionalism but various different ways of designing and re-designing professionalism and the relationship with organisations and management. This suggests a ‘need to overcome the hegemony/resistance framework in current analyses of the impact of management on professionalism’, as recently claimed by Numerato et al. [
28], p. 626.
To put it more generally: dichotomous concepts are no longer sustainable. Instead, a more dynamic conceptual approach is needed that moves from the queries of ‘whether’ and ‘why’ the managerial-professionalism relationship is changing, towards the question ‘how’ this happens. This approach pays greater recognition to the contexts, the organisational settings and accountability structures, and consequently, creates new methodological challenges of researching diverse and ‘hybrid’ designs and comparing healthcare systems across organisational setting.
The problems of dichotomies and pre-existing categories in theorising new emergent relationships between medicine and management and their context-dependency direct us back to the need for empirical investigations. The major objectives to be addressed in this research are: to describe new emergent forms of control beyond the metaphor of hybridisation and to analyse context-specific conditions that may foster more integrated clinical management.