Medicine, management, and modernisation: a "danse macabre"?

Publisher Website
Google Scholar
Abstract
Orientations of reform Reforming how clinical work is organised, performed, and monitored has been at or near the top of the policy agenda in most industrial societies for the past 25 years. The reasons for this are: The growing cost of health care, leading to questions about the resource efficiency of existing modes of service delivery Doubts about the appropriateness and value of existing patterns of clinical work organisation Worries about the medical profession's capacity to ensure the accountability of its members. 2 3 These issues are best tackled at the level at which clinical work is performed. When clinicians make decisions about what constitutes best practice, they are also making decisions about how care should be organised. When applying those best practice decisions in their encounters with patients, clinicians are also allocating and spending the health budget. Reform initiatives to address these concerns, however, are characterised by their dependence on “top-down” bureaucratic mechanisms external to individual clinical settings, such as market mechanisms and moral persuasion. 4 5 Examples of these top-down approaches in Britain include capped hospital budgets, tightened spending controls, and an increasing range of performance indicators. Competitive arrangements such as purchaser-provider splits and requirements for provider diversity represent efforts to introduce the discipline of the “market” into health care. Shifting the balance of power towards primary care trusts and the introduction of tariffs based on case mix for service commissioning for these trusts are recent examples of this approach. As with the earlier “internal market,” the policy hope is that these arrangements will stimulate hospital managers to attend more closely to efficiency and quality in service delivery. 6 7 Moral persuasion initiatives have been directed at increasing clinician involvement in clinical audit, quality improvement, and evidence based clinical practice (despite many of these initiatives having emanated from within medicine itself).8 The highly publicised failures of (medical) self regulation in England such as the Bristol and Shipman cases, however, has led policy authorities over the past five years to adopt a more regulatory approach. For example, the National Institute for Clinical Excellence and national collaboratives now set standards for care, which the Commission for Health Improvement uses to assess providers' performance. These are complemented by an extensive national performance framework9 and a national patient and user survey. Policy authorities intend that this clinical improvement agenda will be given local effect via clinical governance mechanisms that make trust boards directly responsible for quality assurance, clinical audit, risk reduction, and related clinical development programmes among staff.10 Healthcare managers, however, need the active participation of healthcare clinicians, especially doctors, to implement these policy initiatives at the level that clinical work is done.11 Whether that active participation is forthcoming depends in part on how the various professions interpret the policy initiatives and on the conflicts of priority that exist even among holders of common objectives.12 These, in turn, are dependent on how the various professions conceive of clinical work.