What characterises the current management ideology?
Since the 1990s, Norwegian public administration, including the health services, has been reformed in the direction of «New Public Management» (NPM) (1, 2). This management ideology is manifested in the health enterprise reform, the interaction reform, hospital reorganisations with large mergers and «crosswise departments» etc. (3). Three characteristics are particularly important:
Simultaneous expansion of market power and government power. New Public Management involves introduction of both market mechanisms and control routines. The ideology borrows freely from the right as well as the left wing of politics. Public administration becomes a strange combination of business and bureaucracy, where the business is characterised by a liberalist mindset and the bureaucracy by an expanding system of monitoring and reporting that signals a fundamental distrust in the health workers.
Demands for loyalty «upwards». The rank and file – we who cater to the fundamental tasks of the health services and bear personal responsibility in the encounter with the individual patients – are faced with a demand for loyalty to our leaders, who in turn are loyal to the levels above. Thus, autonomous professionals are turned into disciplined officials. In New Public Management, independent norms, for example traditional medical ethics and assessments of medical appropriateness, are displaced by what «the line» decides.
Delegation of responsibility and dilemmas «downwards». While loyalty upwards is demanded, responsibility and dilemmas are shifted downwards, initially from the political to the bureaucratic level. The health enterprise reform is a prime example. Now, the general responsibility for the activities of the hospitals no longer rests with the politicians, but with the enterprise boards, as the Minister of Health has repeatedly pointed out (4). In the next round, the dilemmas are delegated all the way down to the rank and file, who must fulfil the obligations of the welfare state without being supplied with sufficient resources. «For example, government ministers may at one point in time guarantee a certain level to all users of care and nursing services, allocate too scarce resources at the next, and subsequently re-emerge as advocates of those who fail to have their rights fulfilled at a third» (5, p. 13).
What are the consequences of the current management ideology for the health sector? New Public Management was introduced for reasons including the need to control public expenditure and public employees. We have no reason to doubt that the intentions were impeccable. Now, however, the baby is being thrown out with the bathwater. Here are some examples:
Poorer clinical services. The capital-city process has not improved the clinical services (6). This is in line with experience internationally (7). Care services for the elderly are already in poor shape in many places, and the interaction reform comprises elements that will exacerbate this situation (8, 9). Experienced doctors must spend so much time on meetings and reporting that the follow-up of patients is significantly weakened. The patients’ confidence in the system erodes. This confidence is not only a key precondition for good services, but also a goal in itself (10).
Financial inefficiency. The alleged potential for cost savings inherent in New Public Management has not been documented. On the contrary: hospital mergers often lead to higher real costs (7, 11, 12). Increasing bureaucratic control in itself represents a cost – today there are more administrators than doctors in Norwegian hospitals. At the same time, control regimes may cause the «rank and file» to be less efficient (13).
Democratic deficit. When responsibility moves from politicians to bureaucrats, power moves with it. Government by the people thereby erodes, as shown by the study of power and democracy (2). Bureaucrats never face elections. When the most important decisions are made in the boardrooms, political discourse erodes into empty rhetoric.
Competence drain. When combined with demands for loyalty, the delegation of dilemmas gives rise to moral conflicts in the individual health worker (14) – (16). One is faced with an impossible choice – loyalty to «the line» versus loyalty to the individual patient. Working ever faster may provide a short-term solution. The long-term effect consists in de-motivated health workers, a declining sense of personal responsibility and exit from the profession (17, 18).
Moral decay. Another possible approach to these conflicting moral pressures is to renounce one’s ideals. A de-humanisation of the health sector may occur if the traditional values of the health professions are displaced by technical-financial vocabularies, ideas and actions. It is symptomatic that the Minister of Health as well as the Prime Minister distance themselves from tragic individual cases that have been brought about by reorganisation and system failure by pointing out that the quality of the health services is high «on average» (4, 19). It will be a sign of moral decay if health workers start thinking in the same terms.
The system of performance-based funding (PBF), another legitimate offspring of New Public Management, provides an apt illustration of many of these negative consequences (20): Clinical services deteriorate in quality, since priority is given to «profitable», rather than «unprofitable» patients. Financial efficiency is weakened – partly because the coding itself steals resources from the primary activities, partly because the incentives embedded in the system shift the activity towards what generates income for the department instead of what would be a sensible use of resources for the community. Moral language is displaced by financial cost-benefit analyses, and being a skilful DRG coder will in some places provide more prestige and career opportunities than being an empathic care worker.
Against this background, it is remarkable to see that the Minister of Health insists on the superiority of the current management ideology (4, 21). This can only be explained by the fact that the ideology has become its own justification – it is not based on empirical verification, nor on rational justifications (3), and moreover it has fully demonstrated its unfortunate effects in other sectors of society as well (22). It can lead the health services in a direction which is diametrically opposed to what the minister professes to desire, and entail a deconstruction of public welfare.
The general practitioners have witnessed how the specialist health services are being surrounded by constantly new layers of administration that complicate their contact with hospital colleagues. The regulatory zeal of the central health authorities reached the general practitioners in 2011, in the form of new draft regulations for the regular GP scheme. They were supposed to ensure the quality of the primary services by regulating the doctors’ activities in detail, under threat of sanctions. The proposal was perceived as expressing distrust in the regular GPs (RGPs). The response came in the form of rapid mobilisation, in which more than two-thirds of the nation’s RGPs united in a letter to the Minister of Health. The letter made it clear that the priorities and choices made by the RGPs should be based on medical considerations, not on the administration’s need for control and regulation (23). While the general practitioners have so far in part succeeded in maintaining their required professional integrity, their colleagues in the hospitals have lost professional terrain during the last decade (24).