The building of a European nation challenges entrenched ties between the state and the professions. Yet, in relation to healthcare, European law is especially weak and professional power is particularly strong. Against this background, the present paper aims to map out the specific configurations of the changing governance of healthcare and the dynamics arising from intersecting contexts of change. We argue that the ‘healthcare state’ is strongly shaped by national regulatory frameworks, while the platform for the power of a self-regulatory medical profession is increasingly international in nature. Across countries managerialism and performance measures together with evidence-based medicine and clinical guidelines are meant to improve the accountability of professionals and the safety of the public. However, the new regulatory tools may also have the opposite effect and indeed serve as a means to reassert professional power; here, the heightened internationalization of healthcare even provides new opportunities. We use material from different countries gathered in a number of research projects to assess the changing governance of healthcare and its contexts. The paper concludes by highlighting the significance of both national regulatory frameworks and (international) professionalism.

The building of a European nation challenges entrenched ties between the state and the professions, in particular medical power. Yet, in relation to healthcare, European law is especially weak and professional power is particularly strong and firmly linked to national welfare states. We argue that the ‘healthcare state’ (Moran 1999) is strongly shaped by national regulatory frameworks. Across different health systems medical power is embedded in specific sets of institutional regulation and organizations of healthcare (Allsop and Baggott 2004; Bourgeault and Mulvale 2006; Burau and Blank 2006; Kuhlmann 2006). Indeed, healthcare states at national level often act as a filter for addressing and adapting to challenges originating from the international level. At the same time, the challenges to profession-state relations occur in an increasingly international context, whereby the basis of the power of a self-regulatory medical profession is more strongly international in nature.

However, change does not only arise from new supranational regulatory bodies and medical organizations. The notion of professional governance itself is also subject to change. Institutional regulation is increasingly complemented with other governance practices, which act through a number of performance measurements and which make for a new ‘scientific-bureaucratic’ form of regulation (Harrison 1998). In the following analysis, we combine approaches from the sociology of professions, new governance theories and the social construction of knowledge. More specifically, we aim to identify intersecting contexts of change at national and international levels, and to map out the specific configurations of the changing governance of healthcare.

The new health policies of managerialism, markets and consumer ‘choice’ change the substance of governance in different ways. The provision of healthcare is increasingly subject to tighter public control. Managerial procedures and performance measures together with evidence-based medicine and clinical guidelines are meant to improve the accountability of professionals and the safety of the public (Lambert et al. 2006). However, the new regulatory tools may also have the opposite effect and indeed serve as a means to reassert professional power. Here, the heightened internationalization of healthcare even provides new opportunities, in particular for the medical profession. As such, the tensions arising from changing national regulatory frameworks and international modes of medical self-regulation may create their very own dynamics in a changing Europe.

We begin by disentangling the knowledge-power knot of professionalism in the new governance practices and then continue with a discussion of the changing configuration of the state-professions alliance. This is followed by an analysis of national policy maps of medical re-regulation. We use material from five countries – Denmark, Norway, Germany, Italy and the UK – gathered in a number of research projects1 to assess the changing substance of governance of healthcare and its contexts especially at national level; the focus is on the medical profession as the key player in all health systems. The countries selected for the analysis represent a range of different European healthcare systems and we focus on governance through performance. The paper concludes by highlighting the significance of both national regulatory frameworks and (international) professionalism in healthcare.

Knowledge is the key to professional power and an essential feature of professionalism (Freidson 1986; Thorstendahl and Burrage 1990). According to poststructural and Foucaudian approaches this ‘knowledge-power knot’ is socially constructed and constituted via discourse and culture. The construction of knowledge and its transformation into power relations is part of a broader concept of ‘governmentality’ and brings into view the ‘technologies’ and procedural nature of the knowledge-power knot (Foucault 1979; see also Johnson 1995; Flynn 2004). In the following, we focus on the governance through performance, which amalgamates scientific biomedical knowledge and managerialism in complex ways and which as such is a key example of the new arenas of knowledge production and legitimization (Kuhlmann 2006).

The new regulatory models are driven by the assumption that the standardization of knowledge and the inclusion of new actors in the negotiation processes improve both the accountability of professions and citizenship rights. As a result of marketization in healthcare there is an increasing need for reliable data to allow for informed decisions and improve the safety of patients and the public at large. New regulatory tools rely on the power of seemingly objective and neutralized information to transform the relationship between professions and service users, and also allow for greater control. Within this context medical governance is a key arena of change and evidence-based medicine, in particular, provides a blueprint for new patterns of ‘making’ legitimate knowledge. Clearly defined standards of care and formalized codes of knowledge based on scientific evidence are meant to reduce unwarranted practice variations among different provider organizations together with interest-based strategies of the professions.

However, the transformation of power relations through new modes of governing performance cannot be taken for granted as health policies often promise. The power of professionalism is based on both formalized codes of knowledge and the ‘mystic’ of exclusive knowledge based on clinical experience (Turner 1995). The governance through performance clearly shifts the balance towards formalization and introduces new criteria of legitimate knowledge. Controlling professions through formalized codes, however, ignores the fact that it is the members of the medical profession who develop such tools, who do the research and who produce the evidence on which policy decisions as well as the ‘choice’ of the service users are based. It is the international medical journals that disseminate relevant knowledge and furnish the knowledge with scientific authority. At the same time, medical power and the belief in biomedical knowledge are also deeply embedded in the culture of Western states and their individual citizens.

The ‘symbolic authority’ of evidence-based medicine in clinical decision-making (Lambert et al. 2006: 2613) is nurtured by all actors in healthcare, and in this respect evidence-based medicine is a genuinely transnational force. Evidence-based medicine is not simply imposed on physicians but marks a paradigmatic change in medicine (Goldenberg 2006). This leads us back to the capacity of professionalism to transform itself. The standardization of care through clinical guidelines and evidence-based medicine provides new opportunities for the medical profession to apply the technique they know best. Physicians’ voices are also the strongest when it comes to deciding what is ‘evident’ and what is not, even under managerial conditions. McDonald and Harrison conclude from developments in the NHS that participation in the guideline process ‘functioned primarily as a device by which actors hoped to pursue their existing opinion, either through imposing them on others, or by creating a framework of legitimation for themselves’ (McDonald and Harrison 2004: 223).

The potential of evidence-based medicine to strengthen medical power, instead of weakening it, lies in the knowledge base and the claims to the authority of science (Harrison 1998; Timmermans and Berg 2003). This draws attention to the ties, rather than the contradictions, between scientific biomedical knowledge and managerial and economic knowledge. Both knowledge systems are based on paradigms of neutrality and objectivity. Both are reductionist and positivist in claiming the one and only truth, and thereby exclude diversity, subjectivity and the context of knowledge production and use. The merger of medical science and managerial tools to scientific-bureaucratic medicine is a powerful means to eliminate subjectivity and context, and even intensify the ‘conquering gaze’ of biomedicine.

This does not mean to deny space for action and resistance. However, an important limitation of the new governance practices is that they introduce managerial criteria, but do not radically transform the underlying knowledge system. On the contrary, medical governance may even reinforce positivism and the belief in objectivity and neutrality of science. Consequently, new players and governance practices do not necessarily shift the power away from the medical profession. Although the formalized codes of biomedical knowledge, particularly evidence-based medicine, are a highly internationalized mode of governance, their impact on healthcare depends on context. In this respect, institutional environments and nation states model the conditions of change. In the next section, we discuss the broader context of the redefinitions of the state-professions alliance before turning to national policy maps in the subsequent section.

The work of early sociologists, such as Weber, Parsons and Durkheim already addressed the relationship between the state and the professions and its changing nature in modernizing societies. The controversies about the state-professions alliance shape past and present debates in the sociology of professions (see, for an overview, Evetts 2006). Healthcare, in particular, has served as a blueprint for theorizing and researching this alliance (e.g., Johnson et al. 1995; Freidson 2001). Moran argues that ‘partnership with the state deeply implicates professions in nation state power, and the distinctive state traditions mean that the institutions, the political cultures and historical experiences of different national professions, vary greatly’ (Moran 2002: 20). From this perspective, professionalism is fundamentally a national strategy for regulating labour markets (Moran 2002).

Several scholars highlight the tensions and ambivalences embedded in this strategy and, in turn, the state-profession alliance. One important tension is the ‘duality of the modern professional practice finding itself torn between the body-citizen (the state) and the individual person’ (Bertilsson 1990: 131). Another dimension of the ‘dualism’ embodied in professionalism is that between altruism and professional self-interest (Saks 1999). Another strand of the literature emphasizes the key role of knowledge as the ‘currency of capitalist societies’ and competition in the occupational fields (Larson 1977; Abbott 1988; Thorstendahl and Burrage 1990; Freidson 2001). This approach brings to the fore a third dimension of ambivalence and ‘dualism’: successful professionalization embodies a system of codification and standardization of knowledge, which at the same time can be used as a strategy to control professionals (Johnson 1995; May et al. 2006). It is in this respect that professionalism and the entrenched expert knowledge system may act as a host for governance practices.

The double role of professions as public ‘officer’ and public ‘servant’ and the increasing centrality of knowledge and experts in modern societies bring into view the ambivalence embedded in the state-profession alliance. This ambivalence allows for a great ‘elasticity’ of professionalism and transformability to new demands arising from changing health policies and new demands on citizenship (Saks and Kuhlmann 2006). Under the changing conditions medical power may thus at the same time be challenged and reassured. Importantly, how the new challenges to medicine play out, depends on national regulatory frameworks and policy maps. To better understand the dynamics of the re-configurations of the state-profession alliance we take a closer look at governance theories and debates on changing welfare states.

Newman (2001) introduces an approach to governance that combines social and cultural, as well as institutional practices. She highlights the dynamics and instabilities of the remaking of governance and thereby challenges the notion of a uniform direction of change. This rests on the notion that changes in governance require a ‘remaking of people, politics and public spheres’ and is not simply the result of either pressure from above or from below (Newman 2005). Similarly, Clarke turns our attention to ‘people’ and conceptualizes governance arrangements as ‘political-cultural formations, rather than as constitutional or institutional systems whose meaning is self-evident’ (Clarke 2005: 17; see also Carmel 2005). In applying this approach to the making of a European people he is able to provide a more fine-tuned analysis of Europeanization that goes beyond institutions and legal frameworks. Both authors insist on the significance of the nation-state but offer a broader framework of governance. This approach may be helpful for the study of healthcare states and (international) professionalism, because it is able to capture different types of governance practice and the connections between them.

One characteristic of the changes in governance is the increasing turn towards managerial steering and performance that in turn shifts power to the meso level of organizations and professions. Consequently, professional knowledge and expertise and the methods of defining, measuring and evaluating knowledge are becoming part and parcel of governance practices. To this end, the new forms of governing through performance may even strengthen the power of professionalism acting as a means of occupational control. Evetts (2003, 2006) has highlighted that the discourse of professionalism can be used in varied ways and may play out differently in established and new professional groups. However, there may also be variations within the medical profession – as an archetype of profession – itself, which have not yet been studied in the context of changing governance.

Another characteristic of the changes in governance is what is termed ‘globalization’, which operates within a neoliberal market logic prevalent in public services. As a consequence the institutional framing of professionalism is becoming increasingly international in nature. Following Moran (2002): 29), ‘globalization is subjecting traditional professional hierarchies to immense stress’. Similarly, Coburn (1999) emphasizes the challenges of globalization for medical power. However, new challenges are only one side of the coin. The medical profession does not only increasingly operate internationally through its self-governing bodies, the very nature of expert knowledge and the cultural belief in biomedicine are also highly ‘globalized’ means of governance. These means operate effectively across, below and above the borders of nation states, and increasingly become relevant in different health systems. Doctors not only face new challenges, but also new possibilities to actively model and remodel the ‘technologies’ of governing through performance. Here, the notion of ‘transnationality’ may be helpful to understand the power of a free floating global professionalism, created at an international level and heavily biased towards Anglo-American concepts and data sources, but operating in the context of national settlements and policy processes.

Characteristically, both the ‘managerial state’ at the national level (Clarke and Newman 1997) and globalization indicate a changing concept of state power, though the implications for the state-profession alliance may be distinctive. We can therefore expect tensions that enhance complex, and even contradictory dynamics in the state-professions alliance. Against the background of the broader context of the redefinitions of the state-professions alliance we now turn to discussing policy maps at the national level.

As suggested above, governing medical performance is at the centre of the changes in professional governance. There are two things that are changing with the ‘new’ governance of medical performance. First, the relationship between professional self-regulation and other forms of governing is coming to the fore. Hierarchy is thus not loosing ground, but instead hierarchy is reinventing its role as an active regulator using new combinations of control, incentives for self-governance, and interaction in networks across formal government levels as well as public and private sectors. Second, this also makes for a more explicit regime of governing medical performance. Importantly, the specific characteristic of the new governance of medical performance varies between individual countries reflecting country-specific institutional contexts and associated developmental paths.

We introduce an analytical distinction between three forms of governance: hierarchy, network and professional self-regulation. These categories serve to describe the country specific features of professional governance; although we can find all forms of governance in each of our case studies, the composition varies across countries. Hierarchy is based on formal authority and is concerned with control, standardization and accountability. Centralized systems of standard setting and auditing are an example of this form of governance. Network-based governance is characterized by interdependent flows of power and focuses on adaptation and flexibility. Examples of this form of governance are negotiations of quality standards among purchaser, provider and professional organizations. Finally, professional self regulation relies on expert authority and aims for professional control over practice. Clinical guidelines set by professional bodies are an example of this form of governance.

3.1 The new governance of medical performance: hierarchy and centralization

In Britain, the new governance of medical performance emerges as two separate sets of governing mechanisms centring on clinical governance and revalidation, respectively. This reflects the fact that the private interest government of doctors is quite separate from the rest of the healthcare state; this separation is likely to be reinforced in future following the new policy recommendations (DH 2006). Interestingly, the emerging competition between the two sets of governing mechanisms provides a leverage for change, as reflected in the discussion about the possible integration of governing mechanisms. The fact that collectively the medical profession has not fully succeeded in adapting their strategies to the policy challenges potentially contributes to this process. Here it is indicative that the interests of the medical organizations have often remained fragmented throughout the process of negotiating the new terms of medical governance. This is not least reflected in growing divisions between the rank and file. The implications in terms of the ‘how’ of the governance of medical performance are two-fold: the strengthening of hierarchy-based governance, notably through the introduction of clinical governance; and the addition of network-based governance (in the form of negotiations among medical organizations) to traditionally exclusively professional self-regulation. The first set of developments has been characterized by hectic institution building, although the effect on the workings of medical governance remains uncertain (Salter 2004).

In contrast, in Italy the new governance of medical performance formally presents itself as a more unified approach (Tousijn, W. (2005) Country Report: Italy (unpublished manuscript)). The ‘management by objectives’ reflects the increasing importance of regional, decentralized public management within healthcare. Here, the tensions within the healthcare state, especially between the central and local levels and between public and private elements, have provided leverage for change. Importantly, however, change remains incomplete and here it is indicative that informal negotiations as a form of network-based governance complement the hierarchical management by objectives. In fact, besides the introduction of hierarchy-based governance this is the main aspect that is new in the new governance of medical performance.

In Denmark and Norway decentralized public management also provides the platform for the new governance of medical performance. Contracts between counties and hospitals together with clinical governance in Denmark and the introduction of general management in hospitals together with patient lists for General Practitioners in Norway point to a more hierarchical and above all centralized approach to governing medical performance; but as part and parcel of broader healthcare reforms. In contrast to Italy but also Britain, the changes are also more incremental, at least in the Danish case (Pedersen et al. 2005; Vrangbæk and Christiansen 2005). Possible explanations are that the structures of public management are not only decentralized as in Italy, although this applies to a lesser extent to Norway, but also embedded in a system of formal negotiations and consensus seeking. The development of reform initiatives often also occurs from the bottom-up (Vrangbæk and Martinsen 2005). Further, the tight integration of the private interest government of doctors into the institutions of the healthcare state makes the emergence of a separate strategy based on professional self-regulation (as in Britain) unlikely. A further illustration of the embeddedness of professions in the state is the fact that the historical development of the central Norwegian health administration is seen as an ‘extension of the medical clinic into the state’ (Byrkjeflot 2004: 56; see also Nordby 1989).

In Germany, by contrast, the institutions of the (partly joint) self-administration of insurance funds and doctors together with underlying tensions especially relating to issues of financial control provide the main platform for change (for an overview, see Freeman 1998; Urban 2001; Di Luzio 2004; Rosenbrock and Gerlinger 2004). Here, the new governance of medical performance consists of a wide range of initiatives that are concerned with extending the scope of existing governing arrangements and with changing the underlying logic(s) of governance. This includes altering the balance between professional self-regulation on the one hand and network and hierarchy-based governance on the other, as well as the strengthening of the hierarchical elements in the joint self-administration. As in Denmark and Norway (and in contrast to Britain, and to some extent Italy) change tends to be incremental, not least reflecting the strength of formal negotiations that also involve doctors. This is particularly true in the case of the medical performance that has traditionally been the territory of doctors.

The comparative analysis above suggests a number of things about the new governance of medical performance. The developments in all countries point to the emergence of a more explicit regime of governance and hierarchy-based forms of governing are gaining ground. This also includes some institution building. That is particularly apparent in Britain, where the creation of new regulatory bodies has been at the centre of the policy strand of ‘clinical governance’. The same, although to a lesser extent, is true for Germany with the extension of existing corporatist organizations and the creation of new ones. The introduction of a comprehensive ‘National Model for Quality Development’ in Denmark points to a similar development, involving setting up a jointly funded secretariat to support the development and implementation of the National Model. In all countries except Italy the strengthening of hierarchy has coincided with a centralization of power in governing arrangements. This is particularly significant in relation to Germany, Denmark and Norway with healthcare states that have traditionally been more decentralized.

3.2 Pathways of change: context matters

The prominence of hierarchy in the new governance of medical performance in all five countries is interesting considering the significant differences in institutional contexts. However, differences do come to the fore when looking more closely at the specific nature of hierarchy and the specific ways in which hierarchy is combined with other forms of governing. Here, interesting variations emerge: Britain is characterized by more (centralized) hierarchy with parallel professional self-regulation; in Italy incomplete (regional) hierarchy is combined with informal negotiations; whereas in Denmark, Norway and Germany more and increasingly centralized hierarchy is intertwined with formal negotiations, although the focus of negotiations varies. These variations point to differences in existing pathways of governing medical performance and the underlying institutional contexts.

In Britain for example a strongly centralized command and control healthcare state provides a platform for the considerable strengthening of hierarchical governing. Yet combined with normative institutions that perceive of medical authority as first and foremost based on professional self-regulation this leads to the emergence of a parallel regime based on professional self-regulation. A similar friction exists in Italy but for different reasons. Here, a hierarchical approach to governing in the form of New Public Management has been implanted on an insecure and highly decentralized healthcare state as well as a form of medical authority that is first and foremost based on private practice. This makes not only for incomplete hierarchy but also gives primary place to informal negotiations. In contrast, in Germany hierarchy takes the form of circumscribing, in an increasingly tighter way, the joint self-administration as a form of network-based governing. This reflects the strength of the legacy of formal negotiations between doctors and insurance funds.

In addition, in all countries elements of market (competition) based governance have been introduced taking the form of patient choice, competitive contracting, activity based payment albeit in varying institutional forms and within more or less tightly controlled frameworks. Although there probably has always existed some type of informal benchmarking and ranking, the new feature of current developments is the strong emphasis on formalization and the explicit link to economic incentives. Importantly, however, also here the impact of specific institutional contexts is visible. Compared to other countries Britain is characterized by an extensive set of market mechanisms. This points to the close association between markets and hierarchy: strong markets are predicated upon strong hierarchies (Freeman 1998). It is precisely these forms of hierarchical governing coupled with a high degree of centralization that are especially strong in the case of Britain.

The paper set out to explore the dynamics of the transformations in the governance of healthcare in the context of national healthcare states and medical professionalism increasingly acting as a transnational force. Here, our focus has been on new forms of governing through performance at the meso level. This perspective is able to highlight different flows of medical power: these flows are in part shaped by national institutional regulation and policy maps, and in part by professionalism, based on biomedical knowledge that is increasingly constructed and constituted at the international level, claiming ‘global’ evidence. While a growing (international) professionalism accelerates the flow of medical power and diffusion of knowledge at the national level, the remaking of the healthcare state and medical governance focuses on improving the control of providers and the transparency of services, thus challenging or even limiting medical power. The different flows accelerate ‘turbulence’ that in turn impacts differently in different national contexts.

The findings indicate that a healthcare state with institutionalized involvement of doctors in negotiations tends to model medical professionalism as an indivisible and invincible system of power (for example Germany). Here, medical power is strongly linked to statutory powers and embedded in hierarchical forms of governing. Consequently, international resources of professionalism can be used more effectively as ‘private interest government’ of doctors. In contrast, a more formalized system of involvement of doctors in negotiations together with the integration of governance based on professional self-regulation in other forms of governing, such as Denmark and Norway, may create fissures in the knowledge-power knot. Here, medical power is increasingly becoming a contested and publicly monitored arena of negotiations, where various players compete for ‘evidence’ and legitimacy of expert knowledge. Transnational flows of medical power may be strong, but they need to be validated by knowledge claims of other professionals and the demands of the welfare state and service users. In comparison, the situation is more uncertain in relation to the UK and Italy, where more informal systems exist side by side with hierarchy based governance.

Our conclusions are two-fold: first, the healthcare state strongly remains a national state. Different health systems do not easily converge into a uniform European model, although the remaking of medical governance follows similar goals across countries. Second, medical professionalism operates within national settlements and also as a transnational force. Consequently, a debate about European convergence does not grasp the different dimensions of governance and the agency structures of medical professionalism.

1.

These research projects are ‘Modernising Health Care’, funded by the University of Bremen (ZF 27/820/1; see Kuhlmann 2006) and an international research project on ‘Governing Doctors: A Comparative Analysis of Pathways of Change’, funded by the Danish Social Science Research Council and co-ordinated by Viola Burau. The material used for the case studies has mostly been gathered as part of the latter project, while the Norwegian case study is part of a parallel research collaboration with Simon Neby at the Stein Rokkan Center at the University of Bergen. We are grateful to our colleagues Simon Neby, Brian Salter, Willem Tousijn and Karsten Vrangbæk for allowing us to use material from their country reports.

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Ellen Kuhlmann is Senior Lecturer in the Department of Social and Policy Sciences, University of Bath, United Kingdom. Her main research areas are healthcare and policy; professions; and gender and healthcare. She received a PhD in Sociology and a Master's in Public Health from the University of Bielefeld in Germany, and is trained as a nurse. She is author of Modernising health care. Reinventing professions, the state and the public (Policy Press, 2006) and editor, with Mike Saks, of Rethinking professional governance: International directions in healthcare (Policy Press, 2008).

Viola Burau is Associate Professor in Public Policy at the University of Aarhus in Denmark. Her research interests lie in the comparative analyses of welfare service policies, studies of the governance of expertise and methods of cross-country comparison. She has published articles on the politics and policies of healthcare, the occupational governance of nursing and doctors and issues in comparative research. She is co-author, with Robert H Blank, of Comparative Health Policy (Palgrave Macmillan, 2007) and, with Hildegard Theobald and Robert H Blank, of Governing Home Care (Edward Elgar, 2007).

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