The complexity of governance change: reforming the governance of medical performance in Germany

Abstract

The governance of medical performance is changing and new governing instruments are emerging. Existing analyses highlight the complexity of new governance arrangements, but the more or less dualistic perspective limits the possibility for exploring more fully this complexity. The present article therefore uses recent contributions to the literature on governance 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. Using recent reforms of the governance of medical performance in Germany as a case study, the analysis suggests that the complexity of governance change takes three forms: first, the balance among (hybrid) forms of governance is shifting; second, the nature of individual (hybrid) forms of governance is changing; and, third, both types of change are reflected in tensions not only between but also within (hybrid) forms of governance. As such, the article also contributes to the recent literature on governance by highlighting the centrality of tensions in contemporary governance, which can also occur within both hybrid forms of governance and ;pure' forms of governance.

Getting smarter with data: understanding tensions in the use of data in assurance and improvement-oriented performance management systems to improve their implementation

“…Burau [8] distinguishes four PM ideal types, namely markets, hierarchies, networks and self-regulation. Markets and hierarchies use managerial power and deploy strategies such as performance pay, ranking, benchmarking and competition to achieve their goals.…”

“…Networks and self-regulatory systems rely on professional authority and use clinical standards, codes of practice and monitoring through peer review. Although these systems are philosophically at odds, analyses of new public management reforms in Britain [9] and more recent case studies in Germany, Denmark and New Zealand [7, 8, 13], point to the emergence of hybrid systems in which countries use a combination of strategies, but tend towards one or the other, either markets or more self-regulatory approaches, depending on individual histories and the levers available to policy to promote change [7].…”

“…Despite the overwhelming acceptance of PM as a policy tool in many countries [3, 4], implementation is in its infancy [7] and is not unproblematic or without contention. In primary care, PM pushes GPs and general practices into a broader managerial framework of accountability, beyond traditional modes of professional self-regulation that operated at the level of individual patient encounters, and over which the professions had a high degree of autonomy and freedom from regulation [8]. While traditional accountability mechanisms were internally driven, professionally controlled systems, new forms of PM tend to be externally driven, state-based systems using managerial rather than professional forms of regulation [9].…”

How healthcare states matter

“…What is important is that the governance of medical practice has normally been an exception to the rule and consists of strong elements of professional self-regulation in form of voluntary clinical guidelines by specialist medical societies, but that increasingly have been part of a hybrid of networks and hierarchy in the form of joint self-administration and hierarchy in form of framework legislation (Burau, 2007;Igl, 2002).…”

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

“…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.…”