Medicine and management as twin forces: Comparing new modes of control in European hospitals

Across countries, management has brought tighter controls into all areas of clinical practice, responding mainly to financial shortages coupled with increasing public demand for quality and safety of care. Management is not simply expanding and creating new roles for non-clinical managers, but doctors, too, are charged with managerial responsibilities. In this paper we seek to explore how the transformations in medicine and management matter in the control of clinical practice and whether they create opportunities for more integrated, less hierarchical relationships in healthcare. We apply a context-sensitive comparative approach drawing on case study material from seven European countries, namely Denmark, Netherlands, Germany, Poland, Portugal, Spain and Greece; research was carried out by the authors and includes analyses of policy documents, primary and secondary sources and additional expert information. The findings highlight that the transformation in the relationship between medicine and management can take the form of 'hybridisation', 'integration' or more separated 'co-existence' of managerialism and professional self-governing capacities. Interestingly, these patterns may not only vary between countries but also within one organisation depending on both the level of governance (hospital or department) and the area of control (funding or quality and safety issues). The effects of new modes of control are therefore highly complex, diverse and context-depend, including opportunities for remaking professional power. ‘Global’ models of control are not only shaped by institutions when transferred to ‘local’ contexts, but organisational settings and actors also matter, and this, in turn, puts new challenges on comparative health policy mainly concerned with institutional settings.