Performance management, self-regulation and medical dominance in health care: Contradictions and complementarities

This paper examines the intersection between three areas of concern to public administration scholars within the field of healthcare: performance management, responsive regulation and the sociology of medicine. It will offer... [ view full abstract ]

This paper examines the intersection between three areas of concern to public administration scholars within the field of healthcare: performance management, responsive regulation and the sociology of medicine. It will offer insights into the changing role of medical profession within a putative changing pattern of governance marked by move from government based on command and control hierarchy to governance based on principal-agent inspired performance management regimes to a regulatory theory-inspired renewal of self-regulation.

For over thirty years, performance management has been a core element in the rethinking and redesign of public services across industrialised countries. The implementation of performance management typically occurs in publicly regulated healthcare systems and includes elements of hierarchy; and performance management is added onto to existing governance mechanisms which are based on a history of professional self-regulation. Separate from the development of a public management literature on performance management, regulatory scholars have been attempting to transcend the regulation versus deregulation debate. Here effective regulation in conditions of great complexity depends on fostering norms among the regulated such that they will voluntarily comply. In turn, this relies upon establishing an open and regular dialogue between regulators and regulated, known as ‘responsive regulation’. Within healthcare settings, where public management and regulation co-exist, responsive regulation raises whether persuasion and dialogue can play a role in furthering the ambitions of performance management.

In health care settings, further complexity is added by the power of medical professions. Theoretical debates surrounding the existence and extent of medical dominance are concerned with the ability of the medical profession to define the conditions of its work, and the wider societal structuring of the experience of health and illness.

This paper argues that the integration of these three literatures is necessary in order to fully uncover the role of performance management in health care services and the impact of changing governance structures upon medical professions. This paper seeks to examine the regulation of medical professionals in a period of considerable change and increased complexity for health care service delivery as citizen’s expectations grow; there are changes in medical labour markets; shifts in inter-professional boundaries; and a changing role of technology.