Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press of professional autonomy andmedicaldominanceinhealthcare politics. ensuring that all citizens have for responsibility’ access ‘public to a healthcare. and healthcare In non-market-basedboth, with there systems is a state strong tradition profession and regulation are broadly equivalent. Bothof concepts the and countries social,characteristics of demographic haveand economic terms in mature welfare governance in the context of similarity and difference. The two countries arechosen similar as case studies as they allow for the investigation of havethepractices.governance been emergent dynamicsof architectureand UK of The changing nation-based the within out play policies newhow better understand can we so countries, between comparison context-sensitive more a for opportunity governance.professional in governanceprovides an of concept Wethe that argue of healthcare and to highlight the complex factors that may block moveor beyondfacilitate the changecontroversy over self-regulation as a to barrier the modernisation and place self-regulation in the context of other forms of governance. Our aim is state–profession relationships of to configurations national include to governance of throughand Germany the lens of governance. We introduce an expanded concept Kuhlmann andSaks, 2008). and Marceau, 2002; Salter, 2002; Gray and Harrison, 2004; labourDH, and 2006;generating Hunter, considerable 2006; scholarlyof division healthcare the debatein profession medical the (Allsopof dominance customary andthe Saks, 2002; McKinlay Existing 2008). Jones,systems and and of 2007; professionalAllsop Burau, and self-regulation marketisation (Blank have with control come managerial together under increased scrutiny, governance challenging network-based and partnership new of aspect significant a policies. health observe can We trend general a towards are professions health the of governance the in transformations countries,Across Introduction players. associations led network trend regulation that Germany This Key words: This article compares the transformations in professional self-regulation in the UK

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new self- and 173 of Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press funded by compulsory contributions from employers and employees.the and employers While from contributions compulsory by funded Bismarck, model is based on statutory health (SHI) with healthcare jointly funded National Health Service (NHS), the Beveridge model,tax- governance. professionala whilefor frameworks has institutional UK the the The German,and or 174 between different levels of governance: ‘This implies exploring how a specific specific a how exploring implies governance: ‘This of levels different between connectedness the explain can the formations’that explore ‘unsettled to order in more ‘conjunctural’analysis a for argues (2004:25) practices.Clarkegovernance different between intersections the and state the of role changing the highlight governance particular practices shapesthescopefor actionandagencyofthemedicalprofession. of configuration specific the that show They countries. demonstrate that the relative balance between of forms governance varies between also remark of governance, of hierarchicalon the persistence forms but are able to Burau and Vrangbæk (2008), in a comparative study of five European health systems, governance practices. Following heranalysis, shearguesthat: typology of market, hierarchy and networks and a highlighted the introduced interplay of has sets of governance. (2001) of Newman forms different of intersection the on focus and flexibility its governanceis of concept the of strength particular theory.governance to professionsA of study the link to aim analysis,we our In andmethod theory Comparing changingprofessional governance incontext: practices play outinthenationalconfigurationofstate–profession relations. the form of self-regulation. We in conclude shifts regimes;byand highlightingmanagerial and howmarkets through governing changing of governancemodels new bodies; top-down regulatory of areas:reconfiguration three the in governance in the main policy drivers for change in the two countries. We to aim analyseto compare the changes policy context by providing an overviewthat arise inof comparingthe regulatorytransformations structurein professionaland governance, and then move on regulation inthewidercontext of new governance practices. self- professional in transformations explore to which in study case interesting an is a ‘low motion’ system (Freeman, 2000; Burau, 2005). These differences make for been in a period of rapid change, while the conservative-corporatist German system the European context, commentators have noted that the UK healthcare system has two the are to that specific countries.change to In facilitators and createsbarriers reform strategies are similar, the emphasis differs and the form of healthcare politics Thereare areasmajor also difference,of funding of methods the in particular in Although these studies take different perspectives, and vary in their focus, their perspectives,different both take in studies vary these and Although We begin by discussing the concept of governance and the methodological issues 2005: 81) the constitution of citizens as self-governing, responsible subjects. (Newman, governance (governing of through and partnership collaborative patterns strategies), network mechanisms, and market on placed being emphasis more remain governance of forms significant – but the idea of the state as hierarchical a actor unitary is problematised, – with dissolved not is power State Policy &PoliticsPolicy Ellen Kuhlmann andJudith vol 36no 2•173–89(2008) Allsop Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press naturalise themasthe ‘best’ way ofdoingwelfare. These attempts: and formations political-cultural new institutionalise to attempts are policies state pressures forces, welfare changing contradictory that highlights (Clarke,tendencies’25).2004:author and potentially This and multiple by shaped is moment of our analysis, we introduce a distinction between three levels of ‘operational ‘operational of governance’: levels three between distinction a introduce we analysis, our of purpose the governing.For of forms other and self-regulation on questions or’ and managerialism professionalism as conflictingnecessarily logics, priori and the a ‘either/ avoid to helps governance’ in healthcare. The conceptualisation of self-regulation as an element of ‘operational of professionalism and medical power – into a changing architecture of governance in action. an arena in which to observe intersecting governance practices and ‘unsettlements’ is relationship state–profession the actors. of institutional configuration Thus,the medical profession and the ways the state has delegated the regulatory of tasks capacity self-governingto the by particular policy’shaped aredoing of the ‘modes and while simultaneously highlighting their unity’. In healthcare the ‘operational policy’ policy operational and formal both analyse separately to flexibility allowsenough Papadopoulos and it that (2003:governanceis Carmel that of argue powerconcept 32) analytical the ‘the of policy’. doing of ‘mode particular policy the for and procedures delivery and arrangements organisational the as defined is which and,Papadopoulos’sand second, of Carmel notion on (2003) policy’,‘operational ‘actor-centred governance’, which links professional process.governanceaction the in professions andWe draw,agency to of Burau’sfirst, model on institutions; (2005) consequence theorganisationanddelivery ofservices. in governingprofessionalsand of health form particular a self-regulationas see to investigationneeds further to include the powerregulatory therefore, governance, of professionalism and of concept healthcare. The in arrangements stakeholder state– the profession towards relationship and the position of attention the medical profession within particular our direct notions 1990). These (Bertilsson, states professionsthe of position both the as and 1999) ‘servants’and ‘officers’ of welfare the to ‘dualism’professionalin behaviour (Saks,between altruism self-interestand interests of government. Indeed, the a serving number institution, indirectly thus of intermediatory an scholars as conflict ofsocial against the professions have pointed a ‘buffer’as act may profession medical the of capacity self-regulatory noted,the playout. time,same has interruptions the (1992) and StaceyblockadesAt as such Within the health policy process, professional self-regulation is one key arena where The novel feature of our model is the integration of integration the ‘self-regulation’is novelmodel coreThe our the of feature– For our purpose, we expand the concept of governance to specify the role of the have toovercome. (Clarke, 2004: modernization 25,and 29) reform of strategies dominant the that interruptions or current with – way conflicting nation, less welfare. and reform projectsstate to dominant or blockades form They more a in – coexist conceptions ‘residual’ or ‘old’ meanings.... These emergent alternative by engaged and are institutions and commitments meanings, residual or ‘old’ into bump Comparing healthpolicyintheUKandGermany Policy &PoliticsPolicy vol 36no 2•173–89(2008)

and often ideological assumptions about about assumptions ideological often and 175 Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press • • 176 the NHS,the provideswhich healthcare,aroundof 90% employeesareeither doctors annually and the health ratio of to devoteddoctors to (GDP) population Producthas been Domestic low Gross (OECD,of proportion the 2007).countries, Within professionals,doctors.including Historically,health Union European other manyto compared for supply of level the sets also development.state service The for local-level health authorities, now healthcare trusts, and to throughHealth of Department policycare. the through made prescriptionsare allocations resourceAnnual on,arerefers who practitioner general registereda with necessary,as secondary to nationalisation of hospitals and a standardised system of primary care the throughwhere controlexercised access. has patients of state point The the at citizens all for care,freeof spectrum the across NHS the for policy sets Health of Department the through healthcareTreasury, to allocated resources of quantum the the while differ. a has key state the determining UK in the role in system tax-funded the In Germany and UK macro-institutionalthe structures,of in terms arrangements In ofthehealthsystem:The structure contrasting themodels discussion below refersmainlytotheNHSinEngland. the and divergedhave UK the within policies devolution,followinghealth that the differencescritical between Germany and the UK, although it should be noted states. welfare underpin that conditions politico-economic the and systems health of politics and structure the roles.renegotiate resourcesand However, by shaped themselvesare drivers policy the Westernal,et world(Dubois 2006). reallocate to promptedstrategies has This across quality raise and health resourcesfor increase pressure to haveunder come self-regulation medicine,and regulationgovernanceof state the both of terms In Policy contexts anddrivers for change authors, the of each by out carried studies on draws analysis twocountries,the the across To provide an empirical basis for assessing transformations in similar professionalpressures in governanceprofessional governance without assuming linear transformation. of taken be ‘context’to and account allowsdependency’examining This ‘path in ‘new settlements’ within existing configurations of assumptive country comparison. meanings andA particular interests.strength of this approach is to place the creation the latter of with its self-regulatory powers, can be assessed throughempirically cross- Within the nation state, the ‘unsettled formations’ of state–medical profession relations, •

through measures that ‘govern at a distance’ (Miller and Rose, 1990) in the form strategies that impact at the meso-level of health organisations: either directly, or organisational governance arrangements; governance institutional/hierarchical context. self-regulatory arrangements measures;of targetsandperformance 1 documentary analysisandthework documentary ofotherscholars. Policy &PoliticsPolicy : models of governing through markets and managerialist Ellen Kuhlmann andJudith that reflect state–profession relations in a time-specific

Given the significance of context, here we focus on focus context,we here of significance the Given vol 36no 2•173–89(2008) : the regulatory bodies and stakeholder stakeholder and bodies regulatory the : Allsop Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press distributing funds for healthcare, but the responsibility for administration and and administration for responsibility the but healthcare, for funds distributing making andthrough self-governing institutions. centralised policy making1990s, the was contract. Until under combined working carewith medical primary autonomyin are inor clinicaltrusts health decision of and flexible managerialist mechanisms operating within a quasi-market a within operating mechanisms (Gray and flexibleand managerialist by centralised, of hierarchicalregulation, forms with the use of more decentralised existing within resources remain and to that access patients accepted rationed long doctors waiting that times. was bargain This implicit model the is being replaced 1980s,bed’.the double Until the of (1990) politics Klein by‘the politics, termed corporatist elite an through service of conditions and terms safeguarded doctors governancelocal in and making institutions. decision levelthe At making,policy central of clinical in dominance maintained doctors NHS,setting in the standards.role Within major a played has decades recent in oversees and it education professional institutions, specialist other through with Together procedures. disrepute’ into disciplinary profession the ‘brought has performance whose those removeto and doctors register fromregister the to authority sole the has (GMC) Council Medical General licence,the state Under bodies. membership through performance and standards regulated has profession the state,and welfare the to particular functions. In the UK,of monopoly medicine became a a self-governinghas professionboth,medicine prior although,in countries two the in profession Systems, 2000; Freeman, 2000; Dent, 2003). professionalpowerand Moran,(see 1999;Care Health on EuropeanObservatory state between linkage the demonstrates and regulation, corporatist of ‘core’the forms this as care ambulatory on focus article,we this self-employed.In mainly are doctors care as ambulatory of organisation Directive the Time affect not does policies for Europe, have a limited impact. ForLänder instance, the recent European Workingthe of level; regional and national authority both the at under careis hospital and provided by office-based generalists and specialists and overseen by SHI institutions are poorly coordinated. care,Ambulatory uniform whereis especially strong, of is absence the is providergroups of organisations. regime,regulationoccupational and sectors various The Nazi the under experienced centralisation a taken-for-grantedright. and valued culturally providersis of rule,choice freea and than rather exception an recentlywereemployees hospitals.until lists waiting in and salaried Rationing others are most while and specialists, generalists self-employed, office-based are NHS (Maynard and Street, 2006; Blank and Burau, 2007). Roughly 50% of doctors EuropeanUnion other to compared high are expenditure healthcare and population to doctors of ratio powers to regulate the organisation of healthcare and distribution of resources. The statutory with care SHI self-administration’.characterises structure network This of twopillars ‘joint the as funds SHI and Physicians SHI the of with Associations decision making is delegated to a network of ‘public law institutions’ (Moran, 1999) In Germany the state has established a legal framework for collecting and and collecting for framework legal a established has state the Germany In There are important differences in the form of self-governance of the medical the of self-governance of form the in differences important are There of fear a to response a itself corporatism, of form this of consequence One . A second consequence of corporatism is that policy initiatives,policy including that is corporatism of consequence .second A Comparing healthpolicyintheUKandGermany

Policy &PoliticsPolicy countries, and staffing levels are almost twice those of the of countries, those staffing levels twice and almost are vol 36no 2•173–89(2008) 177 Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press earlier alongside a corporatist and decentralised system of regulation (Bäringhausen with the welfare state and compulsory social was introduced much bureaucracy ofenforced self-regulation’. Harrison,2004; Salter, 2007). strategy (2005:latter Dent this termed has ‘soft 632) 178 primary role as containing costs and increasing efficiency. By the second Blair Blair second government, the efficiency. mounting public By pressure to improve increasing services, and enhance patient safety costs containing as role primary exceptions, theself-governing bodies, suchastheChambers, are unaffected. key target group for tighter economic controls (SVR, 2003, 2005, 2007).keygoal,policy profession,medical the with doctors,SHI the Withparticularly and the a few care. the SHI Consequently, become in has cuts containment significant cost the funds, of health providers levels and users all struggle with increasing financial high pressures and by caused incomes unemployment Falling and demographic turned. change has impact directly However, met. recently on situation SHI be funds. economic to the insurance The sickness health of costs rising the allowed has incomes rising with effects. Germany, with policy In consequent prosperity two countries economic the in differently out played also have pressures Economic Policy driversfor change are beingmadetoincrease (Hogg, localscrutiny 2007). structure, although centralised critics the havein embedded pointedand toaccepted is a control democraticand power NHS, state deficitUK and currently attempts and curbing different interests – including those of the state. In contrast, within the governance rather than hierarchical network steering.and partnership of It ideas is embodies basedcare SHI on of the self-administration joint principle of balancing, thus counterbalancing the monopolist power of doctors. As a regulatory model, the interest.public users,the of interestsrepresent the to expected are funds SHI The Physicians and the SHI funds are charged with cooperating to make decisions in the office-based doctors toof population acrossratio geographic areas.the determining Theand fees, Associations negotiating ofspecialists, SHI and generalists among resources distributing as issues,such economic of range a for responsible are and care ambulatory providing in mandatory.monopoly is a have membership Theyscheme; SHI the under care ambulatory provide who specialists and generalists office-based include ethics.Physicians medical SHI updating of The Associations through practice as and well as education continuing and knowledge training specialist accrediting overseeingand professional of standards the controlling for for all doctors on the register (hospital and office-based doctors). They are responsible parallel. UK no haveinstitutions, that SHI of range a UK,and the to Chambers,similar Physicians’the bodies,professional self-governing the both through exercised is powerprofessional where medicine of power.position state the shaped also This external political demands for federalism and decentralisation to mitigate centralised welfare Bismarckianthe to and,back era dates that system Second the after corporatist World a by War, shaped were by arrangements 2002). The Sauerborn, and In Germany, the self-governing powers of the profession developed in parallel in developedprofession the of Germany,powersself-governing In the In contrast, since the inception of the NHS, UK governments have seen their haveseen NHS,governments the UK of inception the contrast,since In Physicians’ Chambers are legally constituted bodies with mandatory membership Policy &PoliticsPolicy Ellen Kuhlmann andJudith vol 36no 2•173–89(2008) Allsop Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press The subsequent public inquiries have demonstrated failures in self-regulation self-regulation in failures demonstrated have inquiries public subsequent The of well-publicisedseries cases where have doctors to patients. harm caused serious Street, 2006). Furthermore, public in trust regulatory systems has been shaken by a allocation to health although with continuing pressure to raise quality (Maynard and and increase patient choice, together with economic growth, led to increased resource effectiveness of new and existing technologies, in particular, has gained England international and Wales), responsible for appraising and producing guidance on the cost- Table 1). The National Institute for Health that and doctors followmanagers and practices leading to Clinicalmore cost-effective careExcellence (see (NICE) (covering length regulatory bodies have been established in the UK, which attempt to ensure arm’s-new of number contrast,underdeveloped(SVR,a 2005).coordinationIn expansion of stakeholders and the introduction of new players is limited and service physicians’and associations,a funds by the governed ‘monolith’sickness solely of longer no is care SHI groups.Although user representativesof include and care The intention is to link the different regulatory systems of ambulatory and hospital SHI care, now the Federal Commission ( of body regulatory key the extended Act Reform Health Germany,2004 In the Transformations ofregulatory bodies using thethree levels of ‘operational governance’ asaframework forcomparison. ‘hybrids’ shall be unpacked and explored in greater detail in the following sections, of governance and forms towardshealthcare‘hybrid’ moving finance are (Lewis et and al, change 2006; organisational Blank continuing and Burau, to 2007). These subject aredeliveryhealthcare. healthcare in consequence,for In systems existing playersmajor the behaviourof the procedureschange to managerial of number a Newman and Kuhlmann, 2007). Both have introduced a raising the form quality of of care,internal market adopting a and so-called ‘third way’ approach (Giddens, 1998;Governments of both countries have aimed to contain costs while at the same time controlling medicalwork Changing modesofgovernance andstrategiesfor and shapethecreation of ‘new settlements’ withinstate–profession relationships. renewal.democratic howexamines section next The differentthe play drivers out wellas as interestscomplex, moreeconomic are including change for drivers the transformations shape the goals of new health policies in Germany,state welfare and while constraints in government.economic Furthermore,the from UK separate more are self-governance of institutions the UK, the state–profession in governance, welfare while of state of part integral configurations an is self-regulation different Germany, medical in relationships: created Germany in and welfare of model healthcare Bismarckian the and UK historical the differently.in The NHS out the of played have trajectories structures institutional and factors state–profession relations (DH, 2007). of restructuring a and process reform radical a DH,2006). triggered have These in (summarised systems regulatory professional and state betweenlinks weakand In sum, while facing similar pressures, the peaks of economic prosperity, political Comparing healthpolicyintheUKandGermany Policy &PoliticsPolicy vol 36no 2•173–89(2008) Gemeinsamer Bundesausschuss ) (see Table 1). 179 Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press (Davies et al,(Davieset treatmentswhich 2006).about make decisions itself not does NICE representativesuser with consults and experiences their evidencefromof patients practice and assesses audit methods. It for hasguidelines al,clinical recommendset developed 2006).also (Concentin It practice based and supported methods to obtain significance as a pioneer in assessing treatment regimes and disseminating evidence- 180 explains thelackofstateactivity inthissphere. to distributions the SHI system releases the state from the burden of costs and thus financial Germany, and in making effect policy In for responsibility of delegation groups.involveconsumer not does it and example,NICE than,for accountable publicly and transparent less is and control medical maintains patients.This for Headed by a physician, its main task is to provide safe, evidence-based information of QualityandEfficiencyinHealthcare’ oftheSHIsystem. wasestablished aspart extent.2004,same In an the ‘Institute to developedinstitutionally been havenot In Germany, to improve efforts standardisation and control of healthcare decisions issuesguidancethatmay bemandatory.in turn should be funded but makes recommendations to the Department of Health, which Table 1: Transformations bodies intheUKandGermany ofregulatory public control New agenciesof bodies Regulatory Transformations arrangements Stakeholder activities new bodiesthatcoordinate various professional groups; bodiesof of regulatory bodies; regulatory councils, members onprofessional the policyprocess; more active involvement in users andnew forms of Inclusion oftheservice (England) NI); Agency (England, National PatientSafety NICE (Englandand Excellence(UK) Regulatory Council for Healthcare health professions (UK); Nine councilsgoverning the UK Policy &PoliticsPolicy Healthcare Commission Ellen Kuhlmann andJudith associationsand vol 36no 2•173–89(2008)

Wales and arange more lay Wales);

Hospital Society; representatives andtheGerman Committee, Restructuring oftheFederal Germany lack ofcoordination ofservices statutory from bodies; theregulatory exclusion ofthehealthoccupations of userinterests totheSHIfunds; alongside theprincipleofdelegation user Inclusion oftheservice evidence-based patientinformation Healthcare; Institute ofQualityandEfficiencyin groupsexpert representatives; programmes; context ofdiseasemanagement Allsop recognition maingoal isto improve inclusionofuser inclusionofuser anumber ofnew new bodiesinthe as a profession; no

Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press included in the Associations of SHI Physicians and apply a position in the middle the in the position in a included Physiciansapply SHI and of Associations professiona of arewho psychotherapists except – now rights statutory the denied are and arenas decision-making from excluded are profession dental and medical the from apart occupations Germany, health workforce. In health entire the to has been for state-sponsored agencies to draw on different forms of expertise (for expertise of different forms drawon to state-sponsoredagencies for been has method one UK, the players. In different by held non-compliance for sanction of forms varying with performance professionalgovern to guidelines and setting (Kuhlmann, 2006). ( gatekeepers as generalists office-based introduce to projects pilot and contracting developed with incentives for organisational change, such as of flexiblenew forms quality (Tophoven, 2003). Following this experience, more complex strategies were but studies suggest that the projects have largely failed to contain costs and improve change, structural introducing and contracting of different ways on projects pilot launched Act Reform expenses.Health out-of-pocket 2000 additional The with have been introduced and the users of healthcare services are burdened increasingly funding.SHI in Co-paymentssolidarity by patients of principle the erosionof an increasingly limited through the exclusion of several services. This is coupled is with care SHI coverageof services,the and base funding its expanding currently is al, 2001). et incentives (Glaeske However,financial on focus NHS and the while UK,the to Similar incentivespolicy areby marketisationshaped and competition system,health the which, NHS,unlikethe purchaser–provider a had alreadysplit. funds, have beenestablished (AllsopandBaggott, 2004). foundation trusts, hospitals within the NHS and with greater financialfacilities freedom to raise NHS for sought been has finance (DH,2004).Private patients for choice widening and competition increasing of objective the with encouraged, (Sheaff et al, 2004). A more pluralist supply system using the private sector has been commissioning agencies, carebetween trusts,the primary care, aremergers taking place at social the meso-level and health across services of coordination the and quality.and recently,Most providerof extent increasethe orderto cooperation in services within a given budget; providers compete for contracts on the basis of cost service pricing. Purchasers now commission services for populations, and prioritise NHS. The aim was to split the functions of purchasing and providing and introduce governance. In the UK, in the early new1990s an of internal market cornerstones was the introduced havebecome in strategies the managerialist and Marketisation oforganisationalNew forms governance: marketisation management andperformance view andmedicalinterests. medical players,the independent counterbalancing as act to professions health of recognitioncomprehensivea and provide range a for jurisdiction opportunity the Statutory Jones,2008).2006, and (Allsop professions health of range expanding coveran bodies regulatory nine currently where UK the developmentsin the to range (European Observatory on Systems, 2000). This is in sharp contrast Hausarztmodelle Differences in the stakeholder are arrangements especially strong when it comes Another cornerstone of the new governance practices is the focus on standard on focus the is practices governancenew the of cornerstone Another In Germany, a of series reform acts demonstrates a commitment to innovation in ). However, is voluntary participation for both providers and users Comparing healthpolicyintheUKandGermany Policy &PoliticsPolicy vol 36no 2•173–89(2008) 181 Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press parties composed of various interests reflecting a more plural approach to policy to approach plural more a reflecting interests various of composed parties in contained Frameworks groups Service (NSFs).National the client haveThese bydrawnworking or up been illnesses particular of treatment the for guidance is an example already mentioned (Davies et al, 2006). Another example is the policy example,maketo users) recommendations policy.for service and clinicians NICE 182 of medical performance is mainly exercised within the SHI system and outcomes and system exercisedSHI mainly the is within performance medical of relative powers of policy actors within the . In Germany, the governance and socialcare divide, isapriority. whereworking,UK the to interprofessional contrast across health the particularly sharp in professions.is health This other with working doctors than care,rather between office-based generalists and specialists, and between ambulatoryfor integrated care and(Greß hospitalet al, 2006). In Germany, integration refers to cooperation effect has been limited (SVR,Germany,the 2005,in but goals 2007)policy withalso are only coordination 1% cross-service of thegreater SHIand budget allocated teamworkcommunitythe settings.in hospital both in and care models Integrated (Saks and Allsop, 2007) and there is a driveconditions. to integrateA large and diverse careworkforce of throughhealth support workers has developedmultiprofessional and pharmacists nurses have some instance,enhanced For professions. roles and in diagnosing organisations and of prescribing for interface a the specific rangeat of management and professional development are aspects of ‘operational governance’ and professionals health between introducing tasks greater a ‘skill-mix’ of care.in Policies resourcehuman of newfor forms distribution the changing to geared players allow toprevail. interest-based strategies the alliance between doctors and sickness funds, and the made absenceby the ofmedical elites powerfulin the UK, externalbut overridden by government. In Germany, about concern the validity of data and the opportunities for misuse, arguments also quality of care, there is opposition to benchmarking standards. Both parties express the on reports produceextensive, morenowhospitals are instance funds for SHI of care (Sauerland, 2001). Although data collected by the medical profession (SVR,and the 2000/01), and there are few sanctions againstto compete thosefor patients who(Kuhlmann, provide 2006). a poor These qualitystrategies remain underdeveloped evaluation with benchmarks, and do not encourage providers to treatment,use qualitythey do not measuresestablish a coherent system of target setting, monitoring and the programmes attempt to improve quality of care through the standardisation of Scheme for Equation SHI funds,Risk the and evaluations with focus on coupled the doctors.financialare effects Theyand only. funds SHI the Although both for 2002, DMPs are shaped by the politics of cost containment and financial incentives clearest sign of intervention in the SHI system (Pfaff et al, 2003). First introduced in which benchmarksstandards and publicises outcomes. Commission,Healthcare the as such bodies arm’s-lengththrough inspection and achievedout audit and throughtargets carrying for managers setting performance meso-level. the at implementation controlling is also This while interests off play of the past. The process allows the state to gain legitimacy, yet maintain a veto and making. This contrasts with the medically dominated, secretive and elitist bargaining In summary, a major factor in explaining these different policy priorities is the is priorities policy different these explaining in summary, In factor major a example of state-led supply-side changes in the UK NHS areA further policies In Germany, disease management programmes (DMPs) for chronic illnesses are the Policy &PoliticsPolicy Ellen Kuhlmann andJudith vol 36no 2•173–89(2008) Allsop Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press to substitute less well-paid staff for more highly-paid professionals. highly-paid more for staff well-paid also are less There substitute to encourage the integration of health and social care as well as the financialto incentivesmeasures and workforceplanning initiativesfor centralised are there NHS the on initiatives by the medical profession and on financial controls. Bydepend contrast,on negotiations between within doctors and sickness funds; policy incentives focus clearly articulated; and there is ongoing public debate on a ‘new professionalism’a ‘new on debate public ongoing is there articulated;and clearly more are institutions specialty for roles leadership strengthened; have networks governance professional response, In 2007). 2006, (DH, locally undertaken but Royal Colleges the by led specialists of recertification periodic the appraisal,and fitness to practise. There will be regularphysicians’ relicensingcontinuingassess of to all doctorssystems basedof onintroduction employeran cases; and disciplinary on adjudicate to tribunal independent an majority; lay a with GMC elected an than rather appointed an accountability.be public to greater achieveis to There elites, are the architecture proposals that of will professionaltransform governance medical by accepted phase,but implementation the Agency.Safety in Currently and deal with poorly performing doctors, for example through the National Patient been closer cooperation between state agencies and the professionalself-governance bodiesmark to a identifynew phase in state–profession relations.practitioner, One consequenceHarold hasShipman, the proposed reforms to the institutions of professional aredoctors proof (Janus ofanincreasing dissatisfaction etal, 2007). doctors struggle with the ongoing cuts in SHI care and the 2006 strikes by hospital (Maynardpractice private Street,and 2006). Germany,In by contrast, office-based from new contracts as have hospital doctors, who can well, gains alsopractices financial their havemade combine manage who NHS practitioners workGeneral with gains as NHS doctors are more highly paid than doctors in (2005) calls other ‘hyper-rationality’.European countries.The loss of autonomy may be balanced by financial as well as ‘gaming’ to reach the targets indicatedset resistanceby government(Hunter,have studies measures. Some in new 2006; responsethe of McDonaldreach to regulatory etwhat the al,Germovto limits 2006;are there Salter, 2007; Waring, 2007) manner, time and place of the doctor’s choosing. The other side of the coin is the that in hospital the in patients treating in autonomy medical of loss a to haveled doctors through various forms of clinical governance. Financial and other imperativestake constraintsprecedence over of knowledge the on based claims expertise and narrow professional interests (AllsopandBaggott, 2004). their contributing knowledge (as in NSFs), and less often government as negotiators to support follow and led state are priorities. Elite doctors are that drawn into the policy policies process but more by often as experts replaced been has NHS old the of corporatism macro-level,institutionalised the the at UK the ways.In challenge traditional relationships between key policy players,governance professional of although in differentforms the Germany,in and changes UK the both In Transformations inprofessional self-regulation and weighing the ‘evidence’ fortreatment interventions. standards monitoring and defining proceduresfor and institutions complex more In the UK, following the Shipman Inquiry (2004) into serial killer, general general killer, serial into (2004) Inquiry Shipman the following UK, the In At the meso-level of management within the NHS, government-driven managerial Comparing healthpolicyintheUKandGermany Policy &PoliticsPolicy vol 36no 2•173–89(2008) 183 Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press include performance management, clinical guidelines and networking. that observed be can professionalism of redefinitions and changes bottom-up An but emerging, context(Royalthe contemporary CollegeofPhysicians, 2005; GMC, 2007). in knowledge, patients professional redefines with that engagement and standards 184 in healthcare through the lens of governancetheory.of lens throughthe healthcare in have Germany and UK The self-regulationprofessional in transformations compare to out set has article This professional governance? What mattersinthe changing architecture ofhealth of healthprofessions more advanced. renewal are stronger and democratic the professionalisation and accountability,and transparency statutory greater recognition of for a pressures led,range state been has contrast,change by UK the services.In and playersnew exclude to interests to avoid transparency, and the politics of cost containment may meet with medical alliances Germany, In temporary mayform funds SHI professionand medical the frameworks and are not simply an outcome of the self-regulatory powers of doctors. (Kuhlmann, 2006). frompatients demand a evenis there if services newbyblocking costs contain to regulated.more service Equally, funds SHI governmentand of interest the in is it service, it would be to contrary the medical interest as fees would be fixed and the coverthe to were funds themselves.SHI If service the for pay must patients but acupuncture offer increasingly event, doctors the rejected.In was work this for funds the from reimbursement but Committee Federal the within negotiations of careexample,wassubject SHI acupuncturethe into of integration the 2004 in providerand groups.services new of inclusion Forthe to barrier a as act also can system (Kuhlmann, 2006;benchmarking comprehensive Burau a and establish to Vrangbæk,attempts 2008).the blocked therefore and The corporatist arrangement DMPs: both the SHI funds and physicians had an interest in avoiding competition to barrier a change and transparency. to create converge players different This of was interests especially the evident how in highlights the process of negotiatingcare benchmarking the for mechanism a on alliances.debate opportunistic The and associations provides the space to bypass public both strategic control and to form configuration of SHI regulation with theGermany, twoin the led, other while pillars state of and been sicknesshas medical UK, fundschange the andprofessions. the In physicians’health by exercised agency the in differences crucial are there byinqualitycircles (Kuhlmann, participation earned 2006). profession.the points,byinstance,controlledCredit be for is can and mandatory become has education al,2005).Continuing et (Hasenbein management quality and medicine evidence-based of language the embraced has profession medical circles of physicians’ have sprung up rapidly. After an initial phase of scepticism, the care. In recent years, community-based, loosely linked working groups and of ‘quality quality the enhance to ownstrategies developedits has profession medical the and styles workingcooperative more support may culture network based locally n emn, hr ae urnl n sgs f uh aia sae interventions, state radical such of signs no currently are Germany, there In In summary, to governing barriers medical areperformance embedded in policy Germany, and UK the both in redefined being is professionalism Although Policy &PoliticsPolicy Ellen Kuhlmann andJudith vol 36no 2•173–89(2008) Allsop Delivered by Ingenta to: University of Lincoln IP : 212.219.220.106 On: Tue, 24 Jan 2012 09:35:46 Copyright The Policy Press existing alongside new organisational governance practices, and, second, link link second, and, practices, governance organisational new alongside existing first, include self-regulation as one element ofthat,ways ‘operational in governance’governance of concept inrelations.the healthcareexpanding Wesuggested have state–profession in practices customary and governance of architecture differing the in out play strategies and drivers policy similar how of study case provideda using document analysis, a survey of office-based physicians and interviews and focus and interviews and analysis,office-based physicians document surveyof using a 1 Note national contexts. more context-sensitive of comparison policy process. To this end, the concept of governance providesthey for opportunities a how and intersect, they how and different governance practices requires an assessment ‘architecture’changing of the of of multiplecontradictory. understanding or levelsAn unintended of governance governance,of forms stronglyother with intersect are that effects with sometimes in future willdependonhow stakeholders exercise various theirpowers. numberof a on itself assert to ‘different fronts’. How developments these play out for possibility settlements’‘new (Clarke, struggles 2004).thus dominance Medical a create governance of arenas practices. various governance meso-levelThe and network-based of expansion radical a produce to combined havedevelopments interventioniststate,byan areincreasinglyplural. stakeholder arrangements These controlledstrongly moregoals. are policy relationships state–profession Although profession bargaining and the state has engaged a broader range of players in has strengthenedsteering in the NHS in ways that have fractured customary of forms state– between health and social care. Hierarchical state-led governance over health policy system careis more divide both of integrated in the and terms primary–secondary medical power. and the entry of new players, such as other health professionals controlwho public may greater challenge both to barrier a as act to tends rearrangement corporatist number of opportunities to reaffirm medical dominance in the policy process. The towardsprovided powerstate,has a interventionistmore this a practice and in funds of sickness the balance overall the in shift a Despite situation. paradoxical a creates framework regulatory network-basedsystem. This SHI self-administered regulatory capacity of medicine is institutionally integrated as of a the cornerstone healthcare.deliveryof and organisation the powerfor responsibility and self- The are shaping how accommodations are reached. In Germany, the state has delegated politics interest-based and frameworks regulatory context.Nevertheless,national professionalismcontemporary constitutes the reassessmentwhat in a of to leading established of that interpretations been professionalchallenge customary self-regulation,have performance medical nation-specific managing of of forms new and bodies regulatory significance the focus into configurations of state–profession relationships. brings In both the UK and Germany, practices new governance andagency. toactors institutional arrangements Data were drawn from: a study on the modernisation of Germany in healthcare of modernisation the on study a from: drawn were Data In sum, our analysis suggests that transformations in medical self-regulation self-regulation medical in transformations that suggests analysis our sum, In care;of organisation supply oversightthe the policy UK,of has the state In the changing of architecture wider the in self-regulation professional Placing Comparing healthpolicyintheUKandGermany Policy &PoliticsPolicy vol 36no 2•173–89(2008) how

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