Revolution from below: The IMPACT of Market-Oriented Management of Hospital Employment in Germany

Internationally, health care has seen the advent of (quasi-)market governance in a public service environment and, concomitantly, the rise of organisational policies derived from private business. Hospitals are a case in point. While still being accountable for the universal delivery of medical services, they are expected to behave like enterprises geared towards earning revenue, sometimes in a regulatory environment featuring free user choice and provider competition. Thus, ‘market accountability’ becomes an issue for hospital management. Exploring the case of Germany, the paper explores how this translates into managerial concepts related to workforce issues including the roles of doctors, nurses, and further staff seeing the patient. We depart from the assumption that employment norms are shaped at sector level rather than in a single hospital but wonder whether this configuration will persist. Following a brief (statistical) overview of the evolving employment patterns throughout the German hospital sector, we examine the labour-related discourse of two sorts of actors: those of major intermediate regulatory bodies (which are critical players in the German health care system) and those entrusted with leadership functions in the hospital itself. Using material from a three-years research project focusing on sense-making processes at sector and organizational level, we can show not only that there is new discourse related to la labour-related issues but also how this discourse is reflected by evolving employment policies. Overall, ‘market accountability’ puts long-established professional concepts under strain. However, the ‘sense-making’ is different between regulators and those who have to implement regulations. This suggests that the rationale of hospital employment is changing bottom-up, often against what regulators conceive as an adequate design for hospital work.