Medical management: hostage to its own history? The case of Italian clinical directors

Abstract

Purpose – As a consequence of new public management reforms, leading professionals in public service organizations have increasingly been involved in management roles. The phenomenon of clinical directors in the healthcare sector is particularly representative of this, as this medical manager role has been adopted in many countries around the world. However, professionals’ managerial role taking still falls quite short of expectations. While most research has searched for the causes of this gap at the individual level by exploring the clash between management and professionalism, the purpose of the paper is to argue that a contextualized understanding of the antecedents at the organizational level, and particularly the existing medical management roles, provides a more thorough picture of the reality. Design/methodology/approach – The paper adopts an institutional perspective to study the development of existing medical management roles and the rise of new ones (clinical directors). The analysis focuses on the case of Italy, a country with a tradition in medical management where, following the example of other countries, clinical director roles were introduced by law; yet they were not incisive. The paper is based on a review of the existing literature and extensive field research on Italian clinical directorates. Findings – The paper shows how in contexts in which doctors in management roles exist and are provided with legitimacy deriving from legal norms, historical settlements between professions and taken for granted arrangements, medical management becomes institutionalized, stability prevails and change towards new doctor-in-management roles is seriously hampered. Originality/value – The paper contributes to existing knowledge on professionals’ managerial role taking, underlining the relevance of contextual and nation-specific factors on this process. It provides implications for research and for policy making in healthcare and other professional public services.

Exploring the link between clinical managers involvement in budgeting and performance

“…The reorganization of hospital activities along the lines of clinical directorates and the introduction of internal budgeting has created the conditions to support devolved financial accountability to medical doctors. As a consequence, in many countries including Italy, the traditional form of medical accountability (internal and professional) has not disappeared, but accountability in the financial sense has been assigned to senior medical doctors who enter clinical manager positions (e.g., Numerato, Salvatore, & Fattore, 2012;Sartirana, Prenestini, & Lega, 2014).…”

“…The motivation for conducting this study in Italy is twofold. On one hand, the Italian health care sector has undergone significant managerial reforms, although the impact of these initiatives on performance has been questioned (e.g., Macinati & Anessi, 2014;Macinati & Rizzo, 2014); on the other hand, the Italian public hospital sector has a long tradition in medical management, and the appointment of senior medical doctors as clinical managers has barged in on wellestablished roles, professional groups, and organizational structures (Sartirana et al, 2014).…”

Making doctors manage… but how? Recent developments in the Italian NHS

“…We have seen how a (limited) group of leading professionals can perform effectively in middle or even top management roles. Therefore, such doctors should be identified and provided with adequate training, administrative staff and delegation of responsibilities from executives [ 28 , 42 ]. Further, these doctors should be paired with nurse managers and other non clinical managers, in order to help them to focus on strategic management and clinical governance issues without jeopardizing their precious time for clinical practice.…”

“…For instance, hygienists maintained their traditional pivotal role in addressing hospital organizational matters, and this worked as a “safety net”, which made the engagement of practicing doctors in management less urgent. Additionally, at least in certain cases, hygienists were also directly opposing the spread of medical management, which was viewed as a threat to the previously uncontested turf [ 42 ]. Furthermore, the processes of doctors’ hybridization were hampered by the poor support that hospitals provided to clinical directors.…”

“…Additionally, there was a lack of delegation from hospital executives; in many hospitals, clinical directors were bypassed and the council of clinical directors never became a real decision making body [ 12 , 28 , 40 ]. Consequently, the in-class managerial training that most doctors undertook was rarely followed by specific opportunities to engage in hospital strategy making [ 42 ].…”