Reflecting on ‘The complexity of governance change: reforming the governance of medical performance in Germany’

Abstract

"The governance of medical performance consists of all those mechanisms that together influence the performance of medical work in terms of either diagnosis or treatment, broadly understood". This definition is at the core of Burau's paper from 2007. The paper uses recent contributions to the public administration/governance literature to "explore the co-existence of different forms of governance with the aim of assessing the relative extent and the substantive nature of governance change" (Burau, 2007). The main contribution is thus to apply governance theory concepts within health care (in Germany) and to illustrate this by analyzing development trends in the governance of medical performance using Germany as an example. The analysis of governance changes in Germany convincingly shows the merits of this type of meso-level analysis for understanding the complexities of governance changes and draws out a number of interesting conclusions.In theoretical terms the paper distinguishes between four ideal-typical forms of governance of medical performance. Professional self-governance is based on expert authority and professional control over clinical practice through peer review and professionally defined clinical guidelines and codes of practices. This type of governance was at the core of the historical compromise between the medical profession and the state, whereby professions gained a privileged status in return for their contribution in rationing health services. However, most industrialized countries have a strong public involvement in health care and therefore also rely on hierarchy, which is the second ideal-typical governance form for medical performance in the paper. Hierarchy is based on formal authority within parliamentary chains of command with politicians at the apex and bureaucracy to support decision making and implementation. Standards for medical performance