Governance and professions are bound in complex ways. As policy experts, organizational managers, lawyers and providers of a wide range of services from teachers, doctors and carers to social workers, the professions serve as mediators between the state and its citizens, while professionalism is oiling the machinery of organizations and service provision (Kuhlmann, 2006; Suddaby & Viale, 2011). Over recent years, new public management (NPM) and marketization, as well as transnationalism and globalization, have challenged these relationships, but the transformations have not weakened the bonding of professions and governance.
Professions have been the target groups of NPM reforms aiming towards greater control and, at the same time, the value of professionalism and the self-governing capacities of professions have been reinvented in the current debates over governance and leadership (Dent, 2005; Teelken et al., 2012; Denis & van Gestel, 2015; HCPC, 2015). Furnished with self-governing capacities, public trust and state support, the professions are perfectly equipped for leadership in public sector organizations. Professionals enjoy overall high levels of trust of the citizens, while doctors and some other health professions are leading the tables in most, if not all, countries (see Chapter 9 by Brown & Calnan). As policy experts, the professions produce the evidence on which public sector services and policy interventions are built (see Chapter 6 by Burau), being able to legitimate unpopular decisions through the power of scientific knowledge (see Chapter 10 by Carvalho & Santiago). Professionals also often act as ‘champions of the people’, thereby protecting the most vulnerable groups in society (Tonkens & Newman, 2011).
This seemingly paradoxical situation of professions being both the ‘officers’ and the ‘servants’ (Bertilsson, 1990) of the public and their dominant role in institutional change (Suddaby & Viale, 2011) calls for a systematic revision of the traditional theoretical concepts in the field of professions. Furthermore, new professional groups and market segments are emerging that lie across traditional national, sectoral, occupational and organizational boundaries, such as, for instance, clinical managers or textile designers (Von Knorring et al., 2010; Bonin & Ruggunan, 2013; Kirkpatrick et al., 2015). Consequently, there is need to shift the focus from ‘boundaries’, ‘contradicting logics’ and ‘social exclusion’ (Larson, 1977; Freidson, 2001) towards the bonds and bridges between professions and governance and the demand for more inclusive forms of professionalism (Kuhlmann & Von Knorring, 2014).
The chapter begins with an overview of the contingencies in the relationships between professions and governance. This includes major challenges like transnationalism and the bonding of professions–organizations–management. This is followed by case studies from the healthcare sector in Germany, Sweden and Turkey that provide in-depth illustrations of how professions and governance are connected in changing societies. Finally, some conclusions are drawn as to whether and how professions and governance are bonded as ‘partners in crises’ rather than counterforces in contemporary public sectors.
The concept of governance and the professions: historical bonds revisited
Governance is described as ‘governing without government’ (Rhodes, 1996), and consequently, closely linked to NPM and leadership. A common denominator of the new governance models is the shift of regulatory power from the macro-level of government towards the meso-level of the organizations and a variety of stakeholders and professional actors (Muzio & Kirkpatrick, 2011; Dent et al., 2012). Governance includes qualitatively new dimensions of regulation and policy that connect different levels of policymaking and may also serve as a tool of policy implementation.
Newman (2005), for instance, described new governance as different sets of governing that include social and cultural, as well as institutional practices. She argues that changing governance is not simply the result of pressure, whether from above or below. Instead, it embodies a remaking of people, politics and public spheres, and complex dynamics rather than a uniform tendency and direction of change (Newman, 2005). From this perspective, professionalism is one specific governance practice that intersects in a dynamic way with other forms of governing (Kuhlmann, 2006). Some authors have discussed these new intersections as ‘hybridization’ of different modes of governing (Tuohy, 2012).
It is important to understand that professions are connected to the state and its governing bodies through a number of ties, as various authors have explained from different theoretical angles (Bertilsson, 1990; Johnson, 1995; Burau et al., 2009). Weakening one tie, therefore, does not necessarily provoke substantive changes. Moreover, professional power needs the support of the state, and the state needs the professions to develop policy and politics and guarantee service provision. However, new governance has transformed national arrangements and also has global effects. New spheres of transnational governance have been created that act above and beyond the nation state; the European Union is a specific example of an emerging mode of transnational governance (Suddaby & Viale, 2011; Faulconbridge & Muzio, 2012; Seabrooke, 2014). How, then, can professions flourish if the key role of the state is transformed by complex governance arrangements, and how do new arrangements affect the role of professions and the concept of professionalism?
The professionals as citizens and mediators
From an historical point of view, the rise of professionalism and the emergence of professional projects are characteristic of civic societies (Bertilsson, 1990). As the new emerging group of experts and knowledge workers, the professions gained full significance in the developing welfare states of the early twentieth century and experienced a ‘golden age’ after World War II (Bertilsson, 1990). Professional power is closely linked to knowledge (Freidson, 1986), but the state has been an important player when it comes to legitimizing the power–knowledge nexus of professionalism (Johnson, 1995). And in turn, professions are highly effective buffers of social conflict, acting as mediators between states and citizens, while professionalism furnishes hegemonic claims of nations, governments, organizations and social groups with the legitimacy and authority of scientific knowledge (for an overview, see Kuhlmann, 2006).
The welfare states had a vital interest in the expansion of professions and professionalism. The concept of the welfare state (regardless of its specific type) promised access to social services for the citizens and this, in turn, has fuelled the provision and expansion of markets for professionalized work. From the public’s perspective, these services offered by the professions became a yardstick for the success of welfare states to translate the concept of social citizenship into the practice of social services. Added to this, professionalism also serves as an ideological model for ‘justifying inequality of status and closure of access in the occupational order’ (Larson, 1977, p. xviii).
The gender order of societies is a prime example to highlight the normative power and important role of professions in modern societies. Historically, professionalization processes were inevitably linked with the social exclusion of women and non-White men. The ‘dominance’ of a few elitist professions, like law and medicine, has been backed up by the ‘deference’ of numerous women (and men), who were either completely denied the status of an expert and professional worker or were clustered in low-status professions, often termed ‘semi-professions’. Professionalization was – and still is to some extent – deeply structured by the gender order of society (Barry et al., 2003; Kuhlmann & Bourgeault, 2008). This order creates ongoing ‘glass ceiling’ effects and status inequality for women in traditionally male-dominated areas, like medicine, despite an increasingly balanced sex ratio in the medical profession at large in most western countries. Also, the gender order serves female-gendered professions like nursing to back up their claims for professionalization and create professional identities, as Wrede (2012) has shown for the nursing profession in Finland.
Hence, changing gender arrangements and increasing professional migration, as well as emergent new economies, have changed the social composition of the professions, thereby challenging professionalism as a White male project of resource-rich countries (Bonnin & Ruggunan, 2013). The traditional forms of boundary work and elitist professionalism in healthcare, backed up by nation-state support are no longer sustainable in times of equal opportunity policies, increasing numbers of women doctors and new demand for skill-mix and task-shifting (Bourgeault & Merritt, 2015). The changes underway in different countries raise more general questions on the logics of professionalism as a mode of organizing the public sector.
US sociologist Freidson (2001) has argued that professionalism is based on knowledge and serves as a ‘third logic’ next to the rational–legal bureaucracy developed by Max Weber, which represents managerialism, and Adam Smith’s model of the free market, which represents consumerism (2001, p. 179). From different theoretical approaches, a major body of the literature has dealt with the formalized knowledge system as a resource for professional power to gain occupational closure and dominance over other groups (Freidson, 1986; and Chapter 10 by Carvalho & Santiago). Viewed through the lens of contradicting logics (Light, 2010), the new modes of governing through performance management appear as external forces imposed on professions that challenge professional power and self-regulatory competencies.
There has for a long time been scholarly debate into the problematic limitations of professionalism as necessarily opposed to other forms of regulation. Johnson (1995), arguing from the perspective of an English sociologist, proposed to overcome the static and contradictory conception of external regulation and professionalism by taking up the Foucauldian concept of governmentality. More recently, integrated governance approaches and a growing body of empirical research into changing boundaries between management and professionalism have added further evidence and expanded the theoretical concepts towards neo-institutionalism and organization studies (Dent et al., 2012; Reay & Hinings, 2009; Suddaby & Viale, 2011; Kuhlmann et al., 2013).
The role of professions in contemporary public sectors can only be fully understood if we bear in mind the double role of professions as ‘officers’ and ‘servants’, as Bertilsson (1990) has argued from the perspective of the Nordic welfare states. Governments across the world need the power of professional knowledge to legitimize political decisions and new policies, in particular in the light of austerity politics and more critical and knowledgeable citizens as service users (Kuhlmann, 2006).
The transformations underway in the public sectors of different countries and the emergent public sector services across the world (see Chapters 16–20, in Part IV) cannot be explained in dualist and dichotomous frameworks, such as ‘from welfare states to neoliberal marketization’. Moreover, professions and organizations are ‘collective agents’, as Muzio and Kirkpatrick (2011, p. 390) argue, with distributed responsibility for public sector services. The ‘collective’ momentum and embeddedness of the professions in publics and public sector services may be best explained by the figure of the ‘citizen professional’ (Kuhlmann, 2006, pp. 15–33; see also Chapter 3 by Tonkens). This approach highlights the bonding of professions and governance and, consequently, calls for a critical review of theoretical explanations into the role of professions in contemporary public sector transformations.
Relocating professions in new emergent spheres of governance
Changes in the relationship between governance and professions and demand for more integrated forms of professionalism are relevant on all levels of governance. Within this context, a more integrated professionalism has many different facets, including more equal social (gender) relationships as well as the softening of occupational boundaries, the new connections between professions and organizations through NPM regimes, and the critical approaches to hegemonic claims for autonomy, to name only some. The qualitatively new dimensions of the bonds between professions and governance are most obvious when looking at new emergent spheres of governance. Here, the politics of globalization, internationalization and Europeanization have created new modes of both transnational governance and agency of professions; this will be illustrated in more detail later in this chapter using gender-sensitive medicine as an example.
As a common denominator of these developments, the different sets of governing (Newman, 2005) are becoming more complex, mixed and permeable. This may lead to processes of ‘re-stratification’ in the professions (Freidson, 2001; McDonald, 2012; Kirkpatrick et al., 2015) that separate the emergent administrative and knowledge elites from a growing body of rank-and-file workers, thereby reinforcing divisions of work and inequality in the professional workforce. However, as Muzio and Kirkpatrick (2011, p. 390) highlight, organizations and professions are ‘collective agents’ and the developments may also ‘represent a way in which professions, as “corporate entities”, are able to reinforce or even extend their dominance over organizations or field of practice’ (2011, p. 396). Similarly, Suddaby and Viale argue that professionals are furnished with:
critical social skills that are essential for effecting field-level change. These skills make professionals uniquely qualified to engage in ‘institutional work’, i.e. creating, maintaining or altering institutions… they shift sides of professional control to new contexts, new vehicles and new organizational fields.
(Suddaby & Viale, 2011, p. 436)
These approaches suggest that professions are not only able to survive in new emergent volatile spheres of governance but are well equipped to actively reconfigure contemporary governance and public sectors. The professions may be relocated in changing public sectors in various ways and new stratifications may emerge, but the bonds between professions and governance are being reinforced, as the examples below highlight in more detail.
Transnationalism: professional agency in volatile spheres of governance
Globalization has created new spaces beyond the regulatory architecture of national states, and this in turn raises a number of new questions about the established bonds between the state, its citizens and the professions and the transformations of these relationships. Despite the centrality of the state in the study of professions (Johnson, 1995), research and theorizing have largely failed to reflect adequately on the geopolitical and cultural contexts of a specific concept of ‘state’ (especially the model of the welfare state and its European roots) that for many years served as a blueprint for the concepts of ‘profession’ and ‘professionalism’.
Only recently have globalization and transnationalism gained more attention in the study of professions, and there is still a lack of comparative approaches. Existing research has highlighted persisting ‘path dependency’ in the country-specific responses of professions ‘to neoliberal institutional pressures’ (Leicht et al., 2009, p. 581). This suggests that the state is still a key actor that determines the scope of professional action, agency and self-regulatory powers (Leicht et al., 2009). At the same time, new supranational and transnational regulatory bodies are increasingly relevant and ‘international organizations are a force encouraging global standards’ (Allsop et al., 2009, p. 487). New bodies and forms of governing beyond nation states may develop their own rules of how to govern the professions (Faulconbridge & Muzio, 2012).
Here, the emergent new field of gender medicine provides an interesting example of how the bonds between governance and professions are tightened up transnationally in the absence of a strong state-government and (conservative) national elites of the medical profession and how this may even transform core concepts of professional knowledge. It is well known that medicine has emerged as a science that is strongly biased towards male actors and based on a masculinist concept of science and the human body that claims ‘neutrality’ of formalized knowledge and supremacy of men’s perspectives over women’s experience. However, the legitimizing power of this approach is on the wane, and a new medical speciality of gender medicine, gender-sensitive policies in major institutions of the healthcare state, evidence-based gender-specific data and gender-specific curricula are emerging in some countries and areas – although slowly and not uncontested.
Changes towards more gender-sensitive healthcare and medicine are fostered by many different players: an international women’s health and gender equality movement, gender mainstreaming policies and equal opportunity approaches of international organizations (like the World Health Organization, the United Nations and the European Union), more gender-sensitive and women-friendly standards and target setting of international research and funding organizations and high-level journals, and regulatory bodies with high international scientific and market power, such as the Food and Drug Administration (FDA) in the USA (for details, see Kuhlmann and Annandale, 2012).
The example of gender-sensitive medicine reveals that a highly conservative medical profession that is firmly rooted in, and tied to nation-state governance arrangements may be re-located in transnational spheres of governance in ways that foster innovation and change in the entire ‘institutional field’, to borrow the term from Suddaby and Viale (2011, p. 436). The developments might in future even lead to restratification processes (like new emergent fields of gender medicine) and more generally, to changes in the knowledge basis of the profession.
Medicine is not the only example of the transformative powers of transnational governance within professional fields. Seabrooke, for instance, has recently introduced the concept of ‘epistemic arbitrage’ (defined as exploitation of opportunities between bodies of professional knowledge) and argued that transnational environments ‘are especially permissive of epistemic arbitrage and professional mobilization’ (2014, p. 49). Furthermore, Quack, drawing on law-making in large international law firms and international legal associations, has revealed that:
in the absence of strong government, transnational law develops, to a significant degree, from decentralized rule-setting led by legal practitioners in large law firms and international professional associations … recurrent efforts of multiple professional actors to make sense of their legal transactions generate a working level of relationships while all of the actors maintain their distinct cultural and institutional reference frames.
(2007, pp. 658, 660)
Taken together, the research suggests that professionalism is embedded in new emergent spheres of transnational governance in public sectors – which increasingly also include private players like large multinational pharmaceutical firms or private NGOs – and that these processes may foster professional agency in new ways.
Hybridization: professions as organizational agents
The hybridization metaphor (Tuohy, 2012) highlights further important changes in contemporary governance. Here, the focus is mainly on the governance shifts towards operational and actor-centred governance and the meso–micro levels of organizations and professions. Developments in the field of healthcare and the new connections between management and professionalism, including new groups of clinical managers, are the most prominent example of these transformations (Saltman et al., 2011; Kirkpatrick et al., 2015).
Changes may impact in the structure and processes of healthcare organizations like hospitals, in the health professions (e.g. restratification processes and new interdisciplinary educational programmes), and in the concept of professionalism (e.g. more inclusive and participatory approaches). Transformations happen in the ‘minds of doctors’ and those of managers (Von Knorring et al., 2010; Kuhlmann et al., 2013) as well as in the organizations and institutions of the healthcare systems (Burau et al., 2009; Saltman et al., 2011). These processes are not always systematically connected and may be uneven and even contradictory, but scholarly debate increasingly highlights their connectedness and this, in turn, calls for critical revisions of the traditional focus on boundaries in the study of professions.
Organizational research and management studies, in particular, have contributed innovative approaches to the professions and management relationships (Muzio & Kirkpatrick, 2011). Several authors have highlighted the blurring of boundaries between professionalism, conceptualized as ‘internal’ mode of governing, and managerialism as an ‘external’ governance approach attempting to improve control and transparency of elitist professional knowledge. For instance, Waring and Currie (2009) have studied the management of knowledge around clinical risks in the National Health Service (NHS) in the United Kingdom and revealed ‘that doctors respond to change through a number of situated responses that limit managerial control over knowledge and reinforce claims to medical autonomy’ (2009, p. 755). Waring and Currie have introduced three categories for an in-depth description of the strategies applied by doctors: ‘co-optation’, ‘adaptation’ and ‘circumvention’. This research brings into view that management approaches and tools are ‘co-opted into professional work as a form of resistance, with professionals being competent in management practice, rather than being co-opted into management roles’ (Waring & Currie, 2009, p. 774). At the same time, doctors may incorporate managerialist logics and work styles, thus transforming professionalism from ‘within’ the profession (Kuhlmann, 2006).
Cross-country comparative research has added further evidence of the bonding of professions to organizational settings and revealed varieties of relocations. For example, Dent and colleagues (2012) have compared medical leadership in England, Denmark, the Netherlands and the USA and highlighted the ways in which national institutions have shaped professional development. Thus, path dependency still matters in restratification processes.
A comparison of changing modes of control in clinical practice in seven European countries has recently shown that healthcare systems make use of both managerial controls and professional self-governing capacities as well as of markets and public controls. But they vary in the ways the different sets of governing and managing professional performance are coordinated (Kuhlmann et al., 2013). Consequently, coordination may serve as a taxonomy for comparing clinical governance. The findings also call for a closer look at the bonds between professionalism and managerialism to better understand the implementation of governance changes and the agency of professions in organizations and healthcare systems.
Furthermore, the example of gender medicine described previously confirms the capacity of medicine to transform its boundaries and innovate its knowledge base in order to respond to new demand and international pressure. Similarly, Plochg and colleagues (2009) have highlighted important transformations underway in medical professionalism to better respond to healthcare needs. Taken together, the findings illustrate what Suddaby and Viale (2011, p. 436) describe from the perspective of institutional/organizational theorists as ‘critical social skills’ of professionals and Quack (2007, p. 636) as ‘decentralized rule-setting’ of professions that make change happen in organizations and the wider public sector, be it law or healthcare services.
In summary, a discourse of hybridization has challenged classic approaches to professionalism as boundary work and exclusionary strategy. At the same time, the hybridization discourse lacks institutional embeddedness and sensitivity to power relations, and it is, therefore, time to bring flesh to the bones of the hybrid professionals. Here, more critical theoretical approaches and empirical research locate the figure of a hybrid professional in the institutional contexts of healthcare systems, thereby identifying organizational settings that foster integrated modes of professionalism, leadership and innovation (Kuhlmann et al., 2013; Denis & van Gestel, 2015; HCPC, 2015; Kirkpatrick et al., 2015; see also Chapters 11–15 in Part III). How the professions are located in these new emergent spheres of governing depends on contexts; and overall, the path-dependencies of the nation states and systems remain strong factors.
Case studies: health professions and governance in Germany, Sweden and Turkey
We have chosen healthcare in Germany, Sweden and Turkey as case studies to illuminate the importance of contexts to professional governance. Healthcare is interesting for various reasons. First, in medicine we find a highly standardized knowledge system and strong international forces that create similar concepts of professionalism and an umbrella for supranational and transnational governance. Second, health policy, organizations and service provision follow similar goals of universal coverage and ‘good’ care for patients. Our case studies below take four major dimensions into account, namely the position of doctors in the institutional governance arrangements, the introduction of NPM reforms, the leadership of doctors, and new forms of clinical management in relation to the state–professions bonds.
While the modes of professionalism and the goals are similar, the institutional conditions and healthcare systems are different. Germany is a classic Bismarckian-style health system with corporatist governance in a high-income country. Sweden is a prime example of a high-income country with universal healthcare and decentralized governance, and Turkey is a middle-income country with a mixed system that combines centralized governance with market reforms (Tatar et al., 2011; Agartan, 2012; Anell et al., 2012; Busse & Blümel, 2014). Thus, the selected cases provide opportunities to explore the bonds between professions and governance in different governance settings and social contexts.
Germany: Professionalism in a corporatist governance system
The Bismarckian healthcare system in Germany is the oldest welfare model in the world. It is based on corporatism, network-based governance and institutional integration of doctors in the major bodies and regulatory settings. This system is characterized by federalism, fragmentation of outpatient and inpatient care and statutory health insurance (SHI), with healthcare jointly funded by compulsory contributions from employers and employees, although mixed forms, including co-payments of patients, are on the increase. The statutory contribution system ensures free healthcare for all citizens that are members of the health insurance funds. Approximately 50 per cent of doctors are self-employed office-based generalists and specialists, while most others are salaried employees in hospitals. All doctors who treat patients that are members of the statutory health insurance funds must, by law, be registered with the regional Association of Statutory Health Insurance (SHI) Physicians.
The state has established the legal framework for collecting and distributing funds for healthcare, while delegating responsibility for administration and decision-making to a network of public law institutions with the ‘Federal Joint Committee’ (Gemeinsamer Bundesausschuss) as its major steering body. The associations of SHI physicians and the SHI funds form the two pillars of the joint self-administration charged with cooperating to make decisions in the public interest. Within this framework, the Association of SHI physicians represents the provider side (including all healthcare professions), while the SHI funds represent the user side. As a regulatory model, the joint-self-administration of SHI care is based on the principle of balancing, and curbing different interests – including those of the state (Blank & Burau, 2014; Busse & Blümel, 2014).
The 2000 Health Reform Act introduced, for the first time, structural change and pilot projects that impacted on the corporatist partnership-based SHI system by strengthening both market and state powers. Within this context, the introduction of disease management programmes (DMPs) for chronic illnesses in ambulatory (outpatient) care are the clearest sign of intervention in the SHI system. First introduced in 2002, DMPs are shaped by the politics of cost-containment and financial incentives for both the SHI funds and the doctors. Although the programmes attempted to improve the quality of care through the standardization of treatment and a number of new models of quality and safety management, they did not establish a coherent system of target setting, monitoring and evaluation with benchmarks. There are also few sanctions against doctors who provide poor quality of care (Kuhlmann, 2006).
In this situation, office-based doctors have taken the tools of management on board, but primarily in those areas where they are able to design the instruments and outcomes, as, for instance, in quality management and the development and implementation of evidence-based clinical guidelines. In contrast, improved rights of patients and better involvement in decision-making were less popular among office-based doctors (generalists and specialists), as shown by a representative survey conducted with office-based doctors in two large associations of SHI physicians (Kuhlmann, 2006).
Another important area of changing governance is hospitals. Besides a diagnosis-related group-based reimbursement system (DRGs), a number of steering tools have been introduced in recent years, mainly attempting to improve control of budgets and providers (especially doctors) coupled with new modes of quality and safety management (Saltman et al., 2011). Here, a recent European comparative study reveals a paradox of corporatist governance: as policy player, the medical profession is integrated in hospital governance (connected through key regulatory bodies, for instance), but in ways that ensure medical power on macro- and micro-levels of governance, even if the balance of power is shifting towards the sickness funds and a more interventionist state (Kuhlmann et al., 2013). The key question, therefore, is no longer whether management and professions are connected, but how the two modes of governing are coordinated.
In the German case, the new forms of governing medical performance have increased the connections between management and professionalism on all levels and areas, but the regulatory bodies and tools are often not adequately coordinated. This leads to some fragmentation in the coordination between the top level of hospital management and the level of the department/unit as well as between budget management and quality/safety management. In this situation, professional powers are strongest at the level of the department and in the area of quality management (Kuhlmann et al., 2013).
In summary, the governance of medical performance has been transformed but remains firmly located in the SHI system. Consequently, the implementation of governance changes depends, first and foremost, on negotiations between doctors and sickness funds. Within this context, the medical profession holds a strong leadership position, also in relation to other health professions. Here, network-based configurations of SHI governance (based on the two pillars of sickness funds and physicians’ associations) and system-based fragmentation of governing powers provide opportunity for doctors to actively transform the bonds between governance, the state and the citizens.
Sweden: professionalism in a universalist governance system
Similar to the other Scandinavian countries, Sweden has a long tradition of a universalist social welfare system, where healthcare is a public responsibility, mainly financed through taxes and hospital care delivered by public providers. In relation to the provider groups, almost all healthcare professionals in Sweden are salaried employees in inpatient and outpatient care, comprising physicians, nurses and a wide range of other healthcare vocational groups.
The Swedish healthcare system is also, by tradition, characterized by decentralization. While the state provides the overall framework for healthcare policy, the twenty-one County Councils/regions are responsible for funding and provision of healthcare services to the population in their respective geographical regions. Consequently, most healthcare reforms are developed and implemented at county-council level and this has created significant variation in the organization and delivery of healthcare services. More recently, reforms are aiming to shift regulatory power towards the state in order to reduce existing regional differences and ensure equal access to services for all citizens (Anell et al., 2012; Blank & Burau, 2014).
Interestingly, the attempt to overcome the problems of decentralized healthcare policy through stronger state-level reforms is marching in step with an increasing significance of new governance instruments on meso- and micro-levels of healthcare governance. More specifically, NPM and market-oriented policies have been part and parcel of health reform in Sweden since the 1990s. These policies were introduced to weaken the regulatory power of the healthcare state and its monopoly on the provision of welfare services (on national and county levels), but also to improve provider control and strengthen the voice and choice of the citizens and service users in healthcare policy.
Clearly, cost efficiency and quality improvement have also been important driving forces of reforms. This includes the introduction of market mechanisms such as a purchaser–provider split and more expanded opportunities for patients to choose their healthcare provider, as well as new forms of privatization of services hitherto not very common in the Swedish system, including the availability of health services fully paid for by the users. This is still the exception and mainly limited to large cities and elective services, however (Anell et al., 2012; Blank & Burau, 2014).
Within the context of NPM and market-based elements of governance, management is enjoying overall higher currency in all areas of healthcare and all provider groups, while quality management is a particularly interesting case to illustrate the multifaceted connections of governance changes. Here, ideas from total quality management (TQM, in Swedish: kvalitetsstyrning) were imported into the new healthcare policy and had a growing influence on both the concepts of management and the day-to-day practice of physicians. The idea of ‘control’ of doctors seems, at a first glance, to be in contrast to the integrated governance structure of the Swedish welfare system and traditionally high levels of trust in the medical professions’ commitment to quality care. However, the focus on control turned out to reinforce the bonds between the state and the medical profession. This was possible due to the importance of high-quality service provision in Swedish healthcare institutions and the general culture that caused a mutual dependency between doctors (as citizen-professionals) and policymakers/government.
Furthermore, NPM reforms and strong commitment to quality management strengthen managerial influence. This has led to an increasingly stronger manager position in relation to the medical profession. Here, the Department Manager Reform of 1997 marked a final step in separating the healthcare manager role and the doctor’s role. It opens the position of clinical department manager (a direct manager over physicians) to professionals or vocational groups other than doctors. Consequently, governance reforms not only transform the medicine–management connections but may also impact more generally on the role of doctors in clinical settings and the position of other health professionals (Von Knorring et al., 2016).
At the same time, empirical research has revealed that the new managers do not develop their own professional identity to respond to new demand for leadership but refer to the medical professions’ behaviour; this may weaken the manager role in relation to the medical profession (Von Knorring et al., 2010, 2016). This result brings tensions and paradoxes into view. According to the logics of NPM reforms and new medical management concepts, the managers are charged with control of doctors and therefore expected to change the legacy of strong state–professions in universalist welfare systems. Obviously, this does not necessarily happen as expected in theory.
In summary, the universalist system in Sweden has a long tradition of close connections between the state and the professions, specifically doctors. This case study illustrates how the bonding may be ‘institutionalized’ and professional expertise integrated into ‘governmentality’, as Johnson (1995, p. 2) put it. As we have seen from the examples, the ‘institutionalization of expertise’ (Johnson, 1995, p. 2) does not easily leave its trajectories into governance just because of a ‘diversification’ in some areas, but it may search out new avenues, for instance through increasingly involving doctors and nurses in management.
Turkey: professionalism in a mixed governance context
It has proven difficult to categorize Turkey’s healthcare system due to its fragmented nature. In terms of financing, it could be considered closer to a social health insurance (SHI) model (Wendt et al., 2013): the three insurance funds – for formally employed workers, retired state employees, and the self-employed – were non-profit financing institutions which collected social insurance contributions. These social insurance contributions were the largest source of funding (43.9%) in 2008 (Tatar et al., 2011). Alongside this SHI system, there was a tax-financed primary care system that provided care through publicly owned and operated healthcare centres. Moreover, unlike in other SHI systems, corporate actors in Turkey, such as the social insurance funds, trade unions and doctors’ associations were not accorded a central role in the governance of the healthcare system. Rather, along the lines of a command-and-control system, many decisions involving the contents of the comprehensive benefits package or methods of remuneration were decided in a top-down manner, and, partly due to its large role in service provision, the central government held day-to-day operating authority.
The 2003 Health Transformation Programme brought about major changes in the financing, provision and regulation dimensions of the Turkish health system. One of the most important changes was the creation of a single-payer system by uniting the public insurance funds under the Social Security Institution (SSI). The Health Transformation Programme adopted new payment mechanisms that emphasized performance, granted public hospitals some degree of autonomy, established the directorate of Public Hospitals Institution, and redefined the Ministry of Health (MoH) as a planning and supervising authority. Improving efficiency and effectiveness of healthcare delivery was assigned a high priority, and new quality standards tied to performance payments were implemented in all hospitals. Thus, market elements were combined with managerialism and expanded the audit and inspection culture.
At first glance, this trend seems to be largely similar to high-income welfare states. However, reforms in middle-income countries such as Turkey combined elements of marketization and managerialism with universalism largely because reforms had to address problems of access to healthcare services and lack of insurance coverage (Agartan, 2012). Second, in the Turkish case, the reforms were devised and implemented in a top-down manner with very limited participation of stakeholders. Third, and most importantly, at least in this initial stage (2003–10), this particular combination of managerialism, marketization and universalism has strengthened state power.
Although Turkey has experimented with NPM reforms within the framework of the Health Transformation Programme, we have not yet observed the parallel changes in governance where the regulatory power shifts from the macro-level of government towards the meso-level of organizations and to a variety of actors. Additionally, major decisions on financing, such as setting the contribution rates and co-payments, are made by the government within the boundaries set by the Health Reform Act (5510), with no influence of corporate actors. The benefits package is also defined by law, and the SSI (the single payer) issues Health Implementation Guides that list the services, prices and service delivery rules for public and private providers (Tatar et al., 2011).
Currently, corporate actors, such as doctors’ associations, do not have a formal role in governing the financing of healthcare services. Rather, professional self-governance is limited to licensing, certification and monitoring of professional conduct. Some of the important corporate actors such as the Turkish Medical Association remain staunch critics of the Health Transformation Programme and believe that the particular combination of managerial and market-based reforms has undermined their professional autonomy. However, the recent wave of reforms that focus on governance and quality improvement create new areas of governance at the meso-level where doctors may play an important role.
First, doctors have always been the backbone of leadership in the Turkish healthcare system, occupying managerial positions in the MoH’s central organization and provincial health directorates as well as in public hospitals. It would be interesting to observe what kinds of opportunities (and challenges) the shifts in the governance of public hospitals towards financial and managerial autonomy would create for doctors. Second, the next phase of reforms (focusing on quality and regulatory issues) may open up new areas for health professions. Recent criticisms of the Health Transformation Programme highlighted the need for building professional interest in quality as well as a culture of quality improvement (OECD, 2014).
Furthermore, there is growing need for new groups of clinical managers in Turkey who may adopt new tools of management, such as evidence-based clinical guidelines, and use them in ways that reflect professional values and priorities. The MoH has played a leading role in developing clinical guidelines in primary care; working groups for frequently diagnosed diseases were established with participation of some of the stakeholders (Tatar et al., 2011). But the MoH needs professions to reach its targets of improved quality and efficiency. In sum, a mixed model of governance is emerging in Turkey, where centralist public governance is combined with new market elements. In this process, new bonds are forming among the state, the professions and the market.
This chapter set out to explore the relationships between governance, professions and professionalism and the changes created by new modes of governing. We have illuminated the bonds between governance and professions and argued the need to overcome static concepts of professions and professionalism as opposed to other forms of governing. Moreover, as citizens and organizational actors, the professions are embedded in the governance of public sectors. Our examples reveal that the bonds between professions and governance are flexible and malleable and, at the same time, shaped by national architectures of governance.
One important conclusion drawn from our case studies is that the goals and the toolbox of governance may be similar across healthcare systems while the impact in the relationship between the state and the professions, as well as between the professions and organizations, may take different forms. Furthermore, processes of relocation of the professions are underway on macro-, meso- and micro-levels of governance that may create new bonds or strengthen existing ones. Consequently, this calls for multi-level governance approaches to explore the intersecting dynamics in the transformations underway in contemporary societies.
The results bring the complexity of transformations and new emergent forms of professionalism into view in ways that we cannot explain in traditional categories of conflict, exclusion and jurisdiction. These effects of changing governance, management and leadership models are perhaps best understood in terms of intersectionality – to borrow a concept from diversity and gender studies. An intersectionality approach suggests that the connection of different sets of governance may create different results depending on how these sets are connected (for examples, see Kuhlmann & Annandale, 2012). Change in one dimension may trigger dynamics in the governance architecture and the organizational settings that open new spaces for the professions as policy actors and organizational agents (Muzio and Kirkpatrick, 2011). Path dependency is important but does not fully determine this space, because different interests may overlap and new alliances may be volatile and less predictable.
Bringing the bonds between professions and governance into perspective may help us to understand the importance of professions as ‘mediators’ between state and citizens’ interests and as ‘change agents’ in public sector policy and services. Viewed through this lens, professions and governing bodies/policymakers – in mature welfare states as well as in emergent capitalist service societies – are bonded by the demand for sustainable public sectors and services for the citizens, although the various players involved in public sector governance may have different ideas on how these goals may best be achieved.
References
Agartan, T. I. (2012) Marketization and universalism: Crafting the right balance in the Turkish health care system. Current Sociology, 60(4), 456–471.
Allsop, J., Bourgeault, I. L., Evetts, J., Le Bianic, T., Jones, K. & Wrede, S. (2009) Encountering globalization: Professional groups in international context. Current Sociology, 57(4), 487–510.
Anell, A., Glenngård, A. H. & Merkur, S. (2012) Sweden: Health system review. Health Systems in Transition, 14(5), 1–187.
Barry, J., Dent, M. & O’Neill, M. (eds) (2003) Gender and the Public Sector. London: Routledge.
Bertilsson, M. (1990) The welfare state, the professions and citizens, in R. Torstendahl & M. Burrage (eds), The Formation of Professions. Knowledge, State and Strategy. London: Sage, pp. 144–133.
Blank, R. B. & Burau, V. (2014) Comparative Health Policy (4th edn). Basingstoke: Palgrave.
Bonnin, D. & Ruggunan, S. (2013) Towards a South African sociology of professions. South African Review of Sociology, 44(2), 1–6.
Bourgeault, I. & Merritt, K. (2015) Deploying and managing health human resources, in E. Kuhlmann, R. B. Blank, I.L. Bourgeault & C. Wendt (eds), The Palgrave International Handbook of Healthcare Policy and Governance. Basingstoke: Palgrave, pp. 306–324.
Burau, V., Wilsford, D. & France, G. (2009) What is it about institutions? Reforming medical governance in Europe. Health Economics, Policy and Law, 4, 265–282.
Busse, R. & Blümel, M. (2014) Germany: Health system review. Health Systems in Transition, 16(2), 1–61.
Denis, J.-L. & van Gestel, N. (2015) Leadership and innovation in healthcare governance, in E. Kuhlmann, R. B. Blank, I. L. Bourgeault & C. Wendt (eds), The Palgrave International Handbook of Healthcare Policy and Governance. Basingstoke: Palgrave, pp. 425–440.
Dent, M. (2005) Post-new public management in public sector hospitals? The UK, Germany and Italy. Policy & Politics , 33, 623–636.
Dent, M., Kirkpatrick, I. & Neogy, I. (2012) Medical leadership and management reforms in hospital: a comparative study, in C. Teelken, E. Ferlie & M. Dent (eds), Leadership in the Public Sector: Promises and Pitfalls. London: Routledge, pp. 105–125.
Faulconbridge, J. R. & Muzio, D. (2012) Professions in a globalizing world: Towards a transnational sociology of the professions. International Sociology, 27(1), 136–152.
Freidson, E. (1986) Professional Powers: A Study of Formal Knowledge. Chicago, IL: University of Chicago Press.
Freidson, E. (2001) Professionalism: The Third Logic. Oxford: Polity Press.
HCPC – Health & Care Professions Council (2015) Preventing Small Problems from Becoming Big Problems in Health and Care. Research Report, London: HCPC.
Johnson, T. (1995) Governmentality and the institutionalization of expertise, in T. Johnson, G. Larkin & M. Saks (eds), Health Professions and the State in Europe. London: Routledge, pp. 2–14.
Kirkpatrick, I., Ackroyd, S. & Walker, R. (2005) New Managerialism and Public Sector Professionalism. London: Palgrave.
Kirkpatrick, I., Hartley, K., Kuhlmann, E. & Veronesi, G. (2015) Clinical management and professionalism’, in E. Kuhlmann, R. B. Blank, I. L. Bourgeault & C. Wendt (eds), The Palgrave International Handbook of Healthcare Policy and Governance. Basingstoke: Palgrave, pp. 325–340.
Kuhlmann, E. (2006) Modernising Health Care: Reinventing Professions, the State and the Public, Bristol, UK: Policy Press.
Kuhlmann, E. & Bourgeault, I.L. (2008) Gender, professions and public policy: New directions. Equal Opportunities International, 27(1), 5–18.
Kuhlmann, E. & Annandale, E. (eds) (2012) The Palgrave Handbook of Gender and Healthcare (2nd edn). Basingstoke: Palgrave.
Kuhlmann, E. & Von Knorring, M. (2014) Management and medicine: Why we need a new approach to the relationship. Journal of Health Services Research & Policy, 19(3), 189–191.
Kuhlmann, E., Burau, V., Correia, T., Lewandowski, R., Lionis, C., Noordegraaf, M. & Repullo, J. (2013) ‘A manager in the minds of doctors’: A comparison of new modes of control in European hospitals. BMC Health Services Research, 13: 246.
Larson, S. M. (1977) The Rise of Professionalism. Berkeley, CA: University of California Press.
Light, D.W. (2010) Health-care professions, markets and countervailing powers, in C. E. Bird, P. Conrad, A. M. Fremont & S. Timmermans (eds), Handbook of Medical Sociology (6th edn). Nashville, TN: Vanderbilt University Press, pp. 270–289.
Leicht, K. T., Walter, T., Sainsaulieu, I. & Davies, S. (2009) New public management and new professionalism across nations and contexts. Current Sociology, 57(4), 581–605.
McDonald, R. (2012) Restratification revisited: The changing landscape of primary medical care in England and California. Current Sociology, 60(4), 441–455.
Muzio, D. & Kirkpatrick, I. (2011) Introduction: Professions and organizations – a conceptual framework. Current Sociology, 59(4), 389–405.
Newman, J. (2005) Introduction, in J. Newman (ed.), Remaking Governance: People, Politics and the Public Sphere. Bristol, UK: Policy Press, pp. 1–15.
OECD (2014) OECD Reviews of Health Care Quality. Turkey 2014: Raising Standards. Paris: OECD.
Plochg, T., Klazinga, N. & Starfield, B. (2009) Transforming medical professionalism to fit changing health needs. BMC Medicine, 7, 64.
Quack, S. (2007) Legal professionals and transnational law-making: A case of distributed agency. Organization, 14(5), 643–666.
Reay, T. & Hinings, C. R. (2009) Managing the rivalry of competing institutional logics. Organization Studies, 30(6), 629–652.
Rhodes, R. A. W. (1996) The New Governance: Governing without government. Political Studies, XLIV, 652–667.
Saltman, R. B., Durán, A. & Dubois, H. F. W. (2011) Introduction: Innovative governance strategies in European public hospitals, in R. B. Saltman, A. Durán & H. F. W. Dubois (eds), Governing Public Hospitals. Copenhagen: WHO, pp. 1–33.
Seabrooke, L. (2014) Epistemic arbitrage: Transnational professional knowledge in action. Journal of Professions and Organization, 1(1), 49–64.
Suddaby, R. & Viale, T. (2011) Professionals and field-level change: Institutional work and the professional project. Current Sociology, 59(4), 423–442.
Tatar, M., Mollahaliloğlu, S., Sahin, B., Aydın, S., Maresso, A. & Hernández-Quevedo, C. (2011) Turkey: Health System Review. Health Systems in Transition, 13(6), 1–186.
Teelken, C., Ferlie, E. & Dent, M. (eds) (2012) Leadership in the Public Sector: Promises and Pitfalls. London: Routledge.
Tonkens, E. & Newman, J. (2011) Active citizens, active professionals, in J. Newman & E. Tonkens (eds), Participation, Responsibility and Choice: Summoning the Active Citizen in Western European Welfare States. Amsterdam: Amsterdam University Press, pp. 201–215.
Tuohy, C. H. (2012) Reform and the politics of hybridization in mature health care states. Journal of Health Politics, Policy and Law, 37(4), 611–632.
Von Knorring, M., de Rijk, A. & Alexanderson, K. (2010) Managers’ perceptions of the manager role in relation to physicians: A qualitative interview study of the top managers in Swedish healthcare. BMC Health Services Research, 10: 271.
Von Knorring, M., Alexanderson, K. & Eliasson, M. A. (2016) Healthcare managers’ construction of the manager role in relation to the medical profession. Journal of Health Organization & Management, forthcoming.
Waring, J. & Currie, G. (2009) Managing expert knowledge: Organizational challenges and managerial futures for the UK medical profession. Organization Studies, 30(7), 755–778.
Wendt, C., Agartan, T. I. & Kaminska, M. (2013) Social health insurance without corporate actors: Patterns of self-regulation in Germany, Poland and Turkey. Social Science & Medicine, 86, 88–95.
Wrede, S. (2012) Nursing: Globalization of a female-gendered profession, in E. Kuhlmann & E. Annandale (eds), The Palgrave Handbook of Gender and Healthcare (2nd edn). Basingstoke: Palgrave, pp. 471–487.