Journal of Health http://hsr.sagepub.com/ Services Research & Policy
Management and medicine: why we need a new approach to the relationship Ellen Kuhlmann and Mia von Knorring J Health Serv Res Policy published online 25 February 2014 DOI: 10.1177/1355819614524946 The online version of this article can be found at: http://hsr.sagepub.com/content/early/2014/02/25/1355819614524946
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J Health Serv Res Policy OnlineFirst, published on February 25, 2014 as doi:10.1177/1355819614524946
Perspective
Management and medicine: why we need a new approach to the relationship
Journal of Health Services Research & Policy 0(0) 1–3 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819614524946 jhsrp.rsmjournals.com
Ellen Kuhlmann1 and Mia von Knorring2
Abstract New Public Management has affected the relationship between corporate managerialism and professional modes of governing hospitals. While doctors’ increasing involvement in management may have positive effects on health care, hospital governance, health care policies and medical education have largely failed to support this change. There is a need for new policies and approaches to support the changing connections between medicine and management that abandons both the military discourse of ‘wars’ and ‘battlefields’ and the new rhetoric of ‘clinical leadership’.
Keywords clinical leadership, health care management, medical professionalism, New Public Management
Introduction While the relationship between medicine and management has never been easy, recent enthusiasm for the New Public Management (NPM) has created additional challenges. Rooted in the idea of improving control of clinicians, NPM has changed the relationship between medical professionalism and corporate management. In many countries, hospital governance now attempts to combine bureaucratic managerialism and professional autonomy coupled with market competition.1 Clearly, there is local variation and evidence of the impact of emergent forms of clinical management on health services and professionalism is scattered and controversial.2–5 Yet, there is an overall trend towards blurring the traditional boundaries of professionalism and managerialism and creating ‘hybrid’ professional– managerial roles. These developments call for participants and policies that better question NPM logics of power and control. We need to understand how medicine and management should relate and how to create supportive institutional, educational and organizational environments.
Medical management: where are we now? Health care policy over the last two to three decades has significantly expanded the scope of management in hospitals. Not only have new managerial roles been introduced but also new modes of governing organizations and professionals through complex forms of
performance management and competition. The appeal of combining governance approaches to improve organizational efficiency and the control of doctors has created a qualitatively new demand not only for integration and coordination of managerial tools and medical professionalism but also for collaboration between clinicians and managers across all levels and areas of hospital management. Recent studies in Europe have revealed that doctors increasingly respond to these challenges by taking on managerial roles.6 Medicine and management are no longer an ‘odd couple’7 but rather act as twin forces with a manager sitting ‘in the minds of doctors’.4 There is also evidence that bringing doctors into management may improve the quality of hospital services. In their study of hospital trusts in the English National Health Service (NHS), Veronesi et al.8 report a ‘significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service
1 Senior Researcher, Institute of Economics, Labour and Culture, GoetheUniversity Frankfurt, Germany 2 Researcher and Lecturer in Medical Management, Medical Management Centre, Karolinska Institutet, Sweden
Corresponding author: Ellen Kuhlmann, Institute of Economics, Labour and Culture, GoetheUniversity Frankfurt, Senkenberganlage 31, 60325 Frankfurt am Main, Germany. Email: [email protected]
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Journal of Health Services Research & Policy 0(0)
providers, especially where doctors are concerned’ as well as in relation to lower morbidity rates. How, then, are these new roles and demands supported by policies, organizations, and clinicians involved in hospital management? One major problem of reform is that new policy bonds between medicine and management do not easily translate into institutional changes and may clash with existing organizational structures and professional cultures and identities. Also, ‘doctors on the board’ do not automatically change the relationship between medicine and management because these doctors are not sitting on boards in their capacity as doctors but as persons with management responsibilities. Moreover, much of the research has been carried out in NHS systems and/or countries where medical power is traditionally more separated from the state regulatory bodies, suggesting that the positive effects of doctors’ involvement might be overestimated. What might be learnt from European health care systems with more integrated forms of governance?9
Systems: the gap between policies and medical education New health care policies and medical education do not march in step with the latter lagging behind.9,10 The gap leaves young doctors with the challenge of balancing the demands of management and medicine and of creating a more integrated identity. For instance, in Sweden doctors are closely integrated in the regulatory bodies and the development of management research is more advanced than in most other European countries,7 though training in management remains little represented in medical education. So what do students and young doctors learn about the relationships between professionalism and management during their training, and how does this prepare for new demands? The work of sociologist Elliot Freidson11 still has a dominant place in the professional debate. If the values of professionalism being necessarily opposed to those of management and markets is what is taught, medical education will not help young doctors to connect medicine and management.
Organizations: the lack of systematic coordination of medicine and management NPM has increased the importance of organizational arrangements to the design of medical management. European comparative research shows that doctors are involved in hospital management on all levels and in all areas, but the mode of coordination between professional–managerial governance and doctors– managers vary.4 Coordination matters in two
ways: regarding hospital and department/unit levels and regarding budgets and quality/safety management. This can be seen in the corporatist health care system in Germany. Most hospitals are governed by a ‘troika’ (comprising a medical, nursing and administrative director) with complex performance management, targeted cost efficiency and a focus on quality/safety. However, the troika structure is weak or even absent at the department/unit level, and there may be different bodies and tools for managing costs and quality/safety. Overall, NPM policies have a stronger impact on the top level of hospitals, while medically led management remains stronger at department level and related to quality/safety. Consequently, organizations do not adequately foster the creation of coherent connections between medicine and management.
Clinical actors: the making of dominant medical identities The dominance of doctors is well researched and serves to highlight problems and limitations of new connections between medicine and management. But research into high-level medical management in Sweden shows that the dominance of the medical profession is not only driven by doctors but also by the managers themselves.12 When top-level managers were asked about their views on the management of doctors, they had a strong focus on the behaviour of doctors rather than on their own or their subordinates’ managerial behaviour. The role of managers seemed to be weaker, more difficult and less defined than the role of doctors. Although this may be a pragmatic response to reduce conflict in everyday practice, ‘the managers use strategies to manage physicians that seem to weaken the manager’s role in the organisation’.12 This highlights the need of supporting new professional identities which might reduce tensions and help improve collaboration between medicine and management.
Medical management: where are we going? NPM has created a paradox that creates challenges. On the one hand, medicine and management were separated precisely to shift power and control to the latter, while on the other hand, this has created a new need for connecting professionalism and managerialism as well as medical and organizational interests. Recent approaches to clinical leadership, particularly in the UK and the USA, respond to these challenges by replacing ‘management’ as a means of control of doctors with the more positive image of ‘leadership’.13 Drawing on the English NHS, Waring14 has recently highlighted the problematic legacy of management
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approaches in this new ‘leadership’ discourse, pointing out ‘how difficult it might be [for individual managers] to balance professional and managerial imperatives’. In this situation, the unsolved challenges of medical management on the system and organizational level have an impact on clinical practice. Consequently, doctors and managers are charged with collaboration and with building bridges, and managers need to balance different identities and demands.12 These are unhealthy conditions where clinicians pay the price for poor organizational coordination of medicine and management. In addition, the policy discourse is still shaped by power and control. Instead of further fuelling a discourse of difference and military metaphors between management and medicine, there is a need for innovation and system changes. Moving forward, health care management calls for new visionary approaches that focus on connections rather than worrying about the correct dosages of management and professionalism. It is important to improve research into organizational settings that foster coordination between the different levels and areas of medical management.4 Also, making medical education (and those of other health professionals) more responsive to the demands of health care systems, including management, is needed.7,9,10 There is still a long way to go towards more integrated professionalism and collaborative medical management, but it is time to leave the tracks and policies that have largely hindered the building of sustainable connections between medicine and management. But where have the policymakers gone and all the ‘managers’ and ‘educators’ who should sign-post the new pathways? Acknowledgements The authors wish to thank their colleagues from the COST Network for collaborative work4 and inspiring discussions.
Funding This article was supported by the FP7 EU COST Action IS0903 ‘Enhancing the Role of Medicine in the Management of European Health Systems: Implications for Control, Innovation and User Voice’ (http://www.dr-inmgmt.eu/) EK received grants (COST IS0903 STSM) for research visits at the Karolinska Institutet.
References 1. Saltman RB, Dura´n A and Dubois HFW. Introduction: innovative governance strategies in European public hospitals. In: Saltman RB, Dura´n A and Dubois HFW (eds) Governing public hospitals. Copenhagen: WHO, 2011, pp.1–33. 2. Braithwaite J and Westbrook M. Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005; 10: 10–17. 3. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011; 43: 535–539. 4. Kuhlmann E, Burau V, Correia T, et al. ‘A manager in the minds of doctors’: a comparison of new modes of control in European hospitals. BMC Health Serv Res 2013; 13: 246. 5. MacIntosh R, Beech N and Martin G. Dialogues and dialectics: limits to clinician–manager interaction in healthcare organizations. Soc Sci Med 2012; 74: 332–339. 6. Numerato D, Salvatore D and Fattore G. The impact of management on medical professionalism: a review. Sociol Health Illn 2011; 34: 626–644. 7. Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010; 38: 673–677. 8. Veronesi G, Kirkpatrick I and Vallascas F. Clinicians on the board: what difference does it make? Soc Sci Med 2013; 77: 147–155. 9. Horsley T, Grimshaw J and Campbell C. How to create conditions for adapting physicians’ skill to new needs and lifelong learning. Policy Brief. Copenhagen: WHO Europe, 2010. 10. Plochg T, Klazinga N and Starfield B. Transforming medical professionalism to fit changing health needs. BMC Med 2009; 7: 64. 11. Freidson E. Professionalism. The third logic. Oxford: Polity Press, 2001. 12. Von Knorring M, de Rijk A and Alexanderson K. Managers’ perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare. BMC Health Serv Res 2010; 10: 271. 13. Horton R. Clinical leadership improves health outcomes. Lancet 2013; 382: 925. 14. Waring J. Looking back (and forwards) at general management: 30 years on from the Griffiths report. J Health Serv Res Policy 2013; 18: 249–250.
Downloaded from hsr.sagepub.com at UQ Library on May 29, 2014
Management and medicine: why we need a new approach to the relationship Ellen Kuhlmann and Mia von Knorring J Health Serv Res Policy published online 25 February 2014 DOI: 10.1177/1355819614524946 The online version of this article can be found at: http://hsr.sagepub.com/content/early/2014/02/25/1355819614524946
Published by: http://www.sagepublications.com
Additional services and information for Journal of Health Services Research & Policy can be found at: Email Alerts: http://hsr.sagepub.com/cgi/alerts Subscriptions: http://hsr.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Feb 25, 2014 What is This?
Downloaded from hsr.sagepub.com at UQ Library on May 29, 2014
XML Template (2014) [24.2.2014–11:01am] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/HSRJ/Vol00000/140006/APPFile/SG-HSRJ140006.3d
(HSR)
[1–3] [PREPRINTER stage]
J Health Serv Res Policy OnlineFirst, published on February 25, 2014 as doi:10.1177/1355819614524946
Perspective
Management and medicine: why we need a new approach to the relationship
Journal of Health Services Research & Policy 0(0) 1–3 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819614524946 jhsrp.rsmjournals.com
Ellen Kuhlmann1 and Mia von Knorring2
Abstract New Public Management has affected the relationship between corporate managerialism and professional modes of governing hospitals. While doctors’ increasing involvement in management may have positive effects on health care, hospital governance, health care policies and medical education have largely failed to support this change. There is a need for new policies and approaches to support the changing connections between medicine and management that abandons both the military discourse of ‘wars’ and ‘battlefields’ and the new rhetoric of ‘clinical leadership’.
Keywords clinical leadership, health care management, medical professionalism, New Public Management
Introduction While the relationship between medicine and management has never been easy, recent enthusiasm for the New Public Management (NPM) has created additional challenges. Rooted in the idea of improving control of clinicians, NPM has changed the relationship between medical professionalism and corporate management. In many countries, hospital governance now attempts to combine bureaucratic managerialism and professional autonomy coupled with market competition.1 Clearly, there is local variation and evidence of the impact of emergent forms of clinical management on health services and professionalism is scattered and controversial.2–5 Yet, there is an overall trend towards blurring the traditional boundaries of professionalism and managerialism and creating ‘hybrid’ professional– managerial roles. These developments call for participants and policies that better question NPM logics of power and control. We need to understand how medicine and management should relate and how to create supportive institutional, educational and organizational environments.
Medical management: where are we now? Health care policy over the last two to three decades has significantly expanded the scope of management in hospitals. Not only have new managerial roles been introduced but also new modes of governing organizations and professionals through complex forms of
performance management and competition. The appeal of combining governance approaches to improve organizational efficiency and the control of doctors has created a qualitatively new demand not only for integration and coordination of managerial tools and medical professionalism but also for collaboration between clinicians and managers across all levels and areas of hospital management. Recent studies in Europe have revealed that doctors increasingly respond to these challenges by taking on managerial roles.6 Medicine and management are no longer an ‘odd couple’7 but rather act as twin forces with a manager sitting ‘in the minds of doctors’.4 There is also evidence that bringing doctors into management may improve the quality of hospital services. In their study of hospital trusts in the English National Health Service (NHS), Veronesi et al.8 report a ‘significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service
1 Senior Researcher, Institute of Economics, Labour and Culture, GoetheUniversity Frankfurt, Germany 2 Researcher and Lecturer in Medical Management, Medical Management Centre, Karolinska Institutet, Sweden
Corresponding author: Ellen Kuhlmann, Institute of Economics, Labour and Culture, GoetheUniversity Frankfurt, Senkenberganlage 31, 60325 Frankfurt am Main, Germany. Email: [email protected]
Downloaded from hsr.sagepub.com at UQ Library on May 29, 2014
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(HSR)
[1–3] [PREPRINTER stage]
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Journal of Health Services Research & Policy 0(0)
providers, especially where doctors are concerned’ as well as in relation to lower morbidity rates. How, then, are these new roles and demands supported by policies, organizations, and clinicians involved in hospital management? One major problem of reform is that new policy bonds between medicine and management do not easily translate into institutional changes and may clash with existing organizational structures and professional cultures and identities. Also, ‘doctors on the board’ do not automatically change the relationship between medicine and management because these doctors are not sitting on boards in their capacity as doctors but as persons with management responsibilities. Moreover, much of the research has been carried out in NHS systems and/or countries where medical power is traditionally more separated from the state regulatory bodies, suggesting that the positive effects of doctors’ involvement might be overestimated. What might be learnt from European health care systems with more integrated forms of governance?9
Systems: the gap between policies and medical education New health care policies and medical education do not march in step with the latter lagging behind.9,10 The gap leaves young doctors with the challenge of balancing the demands of management and medicine and of creating a more integrated identity. For instance, in Sweden doctors are closely integrated in the regulatory bodies and the development of management research is more advanced than in most other European countries,7 though training in management remains little represented in medical education. So what do students and young doctors learn about the relationships between professionalism and management during their training, and how does this prepare for new demands? The work of sociologist Elliot Freidson11 still has a dominant place in the professional debate. If the values of professionalism being necessarily opposed to those of management and markets is what is taught, medical education will not help young doctors to connect medicine and management.
Organizations: the lack of systematic coordination of medicine and management NPM has increased the importance of organizational arrangements to the design of medical management. European comparative research shows that doctors are involved in hospital management on all levels and in all areas, but the mode of coordination between professional–managerial governance and doctors– managers vary.4 Coordination matters in two
ways: regarding hospital and department/unit levels and regarding budgets and quality/safety management. This can be seen in the corporatist health care system in Germany. Most hospitals are governed by a ‘troika’ (comprising a medical, nursing and administrative director) with complex performance management, targeted cost efficiency and a focus on quality/safety. However, the troika structure is weak or even absent at the department/unit level, and there may be different bodies and tools for managing costs and quality/safety. Overall, NPM policies have a stronger impact on the top level of hospitals, while medically led management remains stronger at department level and related to quality/safety. Consequently, organizations do not adequately foster the creation of coherent connections between medicine and management.
Clinical actors: the making of dominant medical identities The dominance of doctors is well researched and serves to highlight problems and limitations of new connections between medicine and management. But research into high-level medical management in Sweden shows that the dominance of the medical profession is not only driven by doctors but also by the managers themselves.12 When top-level managers were asked about their views on the management of doctors, they had a strong focus on the behaviour of doctors rather than on their own or their subordinates’ managerial behaviour. The role of managers seemed to be weaker, more difficult and less defined than the role of doctors. Although this may be a pragmatic response to reduce conflict in everyday practice, ‘the managers use strategies to manage physicians that seem to weaken the manager’s role in the organisation’.12 This highlights the need of supporting new professional identities which might reduce tensions and help improve collaboration between medicine and management.
Medical management: where are we going? NPM has created a paradox that creates challenges. On the one hand, medicine and management were separated precisely to shift power and control to the latter, while on the other hand, this has created a new need for connecting professionalism and managerialism as well as medical and organizational interests. Recent approaches to clinical leadership, particularly in the UK and the USA, respond to these challenges by replacing ‘management’ as a means of control of doctors with the more positive image of ‘leadership’.13 Drawing on the English NHS, Waring14 has recently highlighted the problematic legacy of management
Downloaded from hsr.sagepub.com at UQ Library on May 29, 2014
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(HSR)
[1–3] [PREPRINTER stage]
Kuhlmann and von Knorring
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approaches in this new ‘leadership’ discourse, pointing out ‘how difficult it might be [for individual managers] to balance professional and managerial imperatives’. In this situation, the unsolved challenges of medical management on the system and organizational level have an impact on clinical practice. Consequently, doctors and managers are charged with collaboration and with building bridges, and managers need to balance different identities and demands.12 These are unhealthy conditions where clinicians pay the price for poor organizational coordination of medicine and management. In addition, the policy discourse is still shaped by power and control. Instead of further fuelling a discourse of difference and military metaphors between management and medicine, there is a need for innovation and system changes. Moving forward, health care management calls for new visionary approaches that focus on connections rather than worrying about the correct dosages of management and professionalism. It is important to improve research into organizational settings that foster coordination between the different levels and areas of medical management.4 Also, making medical education (and those of other health professionals) more responsive to the demands of health care systems, including management, is needed.7,9,10 There is still a long way to go towards more integrated professionalism and collaborative medical management, but it is time to leave the tracks and policies that have largely hindered the building of sustainable connections between medicine and management. But where have the policymakers gone and all the ‘managers’ and ‘educators’ who should sign-post the new pathways? Acknowledgements The authors wish to thank their colleagues from the COST Network for collaborative work4 and inspiring discussions.
Funding This article was supported by the FP7 EU COST Action IS0903 ‘Enhancing the Role of Medicine in the Management of European Health Systems: Implications for Control, Innovation and User Voice’ (http://www.dr-inmgmt.eu/) EK received grants (COST IS0903 STSM) for research visits at the Karolinska Institutet.
References 1. Saltman RB, Dura´n A and Dubois HFW. Introduction: innovative governance strategies in European public hospitals. In: Saltman RB, Dura´n A and Dubois HFW (eds) Governing public hospitals. Copenhagen: WHO, 2011, pp.1–33. 2. Braithwaite J and Westbrook M. Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005; 10: 10–17. 3. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011; 43: 535–539. 4. Kuhlmann E, Burau V, Correia T, et al. ‘A manager in the minds of doctors’: a comparison of new modes of control in European hospitals. BMC Health Serv Res 2013; 13: 246. 5. MacIntosh R, Beech N and Martin G. Dialogues and dialectics: limits to clinician–manager interaction in healthcare organizations. Soc Sci Med 2012; 74: 332–339. 6. Numerato D, Salvatore D and Fattore G. The impact of management on medical professionalism: a review. Sociol Health Illn 2011; 34: 626–644. 7. Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010; 38: 673–677. 8. Veronesi G, Kirkpatrick I and Vallascas F. Clinicians on the board: what difference does it make? Soc Sci Med 2013; 77: 147–155. 9. Horsley T, Grimshaw J and Campbell C. How to create conditions for adapting physicians’ skill to new needs and lifelong learning. Policy Brief. Copenhagen: WHO Europe, 2010. 10. Plochg T, Klazinga N and Starfield B. Transforming medical professionalism to fit changing health needs. BMC Med 2009; 7: 64. 11. Freidson E. Professionalism. The third logic. Oxford: Polity Press, 2001. 12. Von Knorring M, de Rijk A and Alexanderson K. Managers’ perceptions of the manager role in relation to physicians: a qualitative interview study of the top managers in Swedish healthcare. BMC Health Serv Res 2010; 10: 271. 13. Horton R. Clinical leadership improves health outcomes. Lancet 2013; 382: 925. 14. Waring J. Looking back (and forwards) at general management: 30 years on from the Griffiths report. J Health Serv Res Policy 2013; 18: 249–250.
Downloaded from hsr.sagepub.com at UQ Library on May 29, 2014
