7.7 Management and public health
Oxford Textbook of Public Health
Management and public health
David J. Hunter
Management and the management process
What is management?
The culture of management
Models of management
The managerial role
The new rationalism and health
Management: science or liberal art?
Planning for health
Management and public health
A new managerial paradigm
Public health and management: towards a synthesis
To be sure, the fundamental task of management remains the same: to make people capable of joint performance through common goals, common values, the right structures, and the training and development they need to perform and to respond to change. (Drucker 1990)
If, as the management specialist Peter Drucker claims, ‘management world-wide has become the new social function’ (Drucker 1990) then this has profound implications for all organizations whether in the business or service sectors. Regardless of whether organizations exist for profit or are non-profit, the responsibilities of the managers running them are essentially the same. They include defining strategy and goals, developing people, measuring performance, and marketing the organization’s services. But this is not to suggest that there are universal ways of managing, or that what works in the private sector must also apply to the public sector. As will be shown, simplistic assumptions about management are not helpful in the context of health care. Arguably, the sector has already endured through successive waves of reform the passing fashions of management consultants with little evidence of sustained success.
Within the health sector, there has been a global revolution in the organization of health services. Management has been held up as the principal instrument through which the supply-side objectives of the reforms can be achieved as well as those which seek to shift the emphasis in health policy away from an exclusive concentration on health services and towards the notion of health in its wider sense. In both these spheres public health is seen as having a critical contribution to make to the management task.
The relationship between management, planning, and public health has been a long-standing, and at times difficult, one. In modern health-care systems, public health needs management more than ever but this reliance, not always recognized or accepted, often causes offence or a feeling of unease because it is regarded in some quarters as leading to unacceptable compromise in respect of the scientific knowledge-based bedrock of the specialty of public health medicine. There is no equivalent science of managing since management is contingent upon particular circumstances and contexts and has no universal application. Hardly surprising, therefore, that considerable ambivalence exists in the relationship between public health and management.
The tension set up by the public health medicine ethos of rational scientific inquiry on the one hand and the management ethos of making change happen on the other can be entirely healthy and creative since the excesses of one can be tempered by those of the other. For instance, sometimes management is about achieving change for which there exists no (or incomplete) evidence that it is the right thing to do or will even work. Conversely, public health specialists have been variously accused of not acting on the results of their scientific enquiries, or of taking too long to complete these when the need for action is pressing, and of being managerially weak or incompetent especially when it comes to the need for political skills in winning support for a particular line of action. The consequence has often been a failure to implement policies or to manage change effectively.
But the relevance of management ‘science’ and planning for public health can only be established if they are seen to contribute to public health’s primary purpose of improving the health of populations. Recent developments in management in many health-care systems around the world which have undergone, are undergoing, or can expect to undergo reform create particular difficulties for public health. During the late 1980s and for most of the 1990s, these centred on market models aimed at improving efficiency through competition, and directed towards the needs and preferences of individual consumers or users of services rather than the needs of communities or populations. Despite a move in the late 1990s away from market-style mechanisms to more collaborative forms of working with a stress on partnerships, the tension between meeting the needs of populations on the one hand and those (plus demands and wants) of the individual on the other poses a special challenge to public health practitioners and managers charged with the task of finding an acceptable balance between them.
Debates about priority-setting or rationing are especially acute at the interface between the individual as consumer and as citizen.
Against this broad context, this chapter is organized into four sections. The first section reviews the notion of management and the management process in general terms. The second considers the evolution of management in the context of health policy and health sector reform in recent years. The third section looks critically at the relationship between public health and management and develops the points made in the two preceding sections. A final section attempts to pull the arguments together and looks ahead to a new synthesis between public health and management in the context of global developments in health-care systems. The implications of these developments for management education, training, and development for public health, and the need for change in these, are considered.
Management and the management process
What is management?
Management is often thought of as a bag of techniques or tools and as a set of particular skills with which those undertaking management need to be equipped. These skills cover planning, financing, personnel, marketing, and contracting. While important, they are not a substitute for the ‘softer’ dimensions of management that stress the importance of essential principles and core values. All too often these cultural aspects are given insufficient attention or are ignored altogether. The ‘hard’ and ‘soft’ sides of management must go hand in hand, with prior attention being given to principles and values.
Management thus has four dimensions:
the culture, principles, and values of management
the structure of management
the techniques employed by managers
the setting, or infrastructure, of management.
Each of these dimensions is considered briefly in turn.
The culture of management
The culture of management is made up of the attitudes and values that help set a pattern of behaviour for actions and opinions. What managers do may be more or less the same in different organizations and countries; how they do it may be quite different. The most important principles and values are as follows.
Management is about people—its task is to make people capable of performing jointly, to make their strengths effective and their weaknesses irrelevant.
Management is about securing commitment to shared values—its primary task is to think through, set, and exemplify those objectives, values, and goals to which all those working in organizations subscribe.
Management is about developing staff—its task is to provide continuous training and development for all members of the workforce.
Management is about achieving results—in a hospital, for instance, results are healed or comforted patients.
Traditional notions of management or administration, particularly in respect of public services, placed the stress on a number of core values such as honesty, fairness, prevention of distortion, inequity, bias, and abuse of office. These values emphasized process controls rather than output controls. In other words, due process was arguably more important than the outputs to be expected from the managerial/administrative arrangements in place. How the job was done was as, or more, important than the results from it.
Conceptions of management since the late 1980s have progressively placed the emphasis on ends rather than means, even if these might be achieved at the expense of guarantees of honesty, neutrality, and fair dealing. It assumes a culture of (public service) honesty as given. In loosening up management, and blurring the division between public and private sectors, in keeping with the latest fashion for public–private partnerships, the extent to which the new management is likely to induce corrosion in terms of the traditional values listed above remains to be tested. Something of a watershed was reached in Britain in 1994 when the issue of corporate governance rose to the top of the health policy agenda in the midst of enquiries by the House of Commons Public Accounts Committee into allegations of fraud and corruption in the British National Health Service (NHS), particularly in the period since the 1991 reforms (NHS Executive 1994). The next section returns to this issue of the new management.
The structure of management refers to the way organizations are designed. They range from tight bureaucratic structures, with clear command and control relationships and strict rules (that is, closed systems), to loose networks with a large degree of discretionary decision-making (that is, open systems). In between, variants such as project-based and matrix structures may be found. Current notions of management favour increasing individuals’ opportunities to make ad hoc decisions, that is, empowering them by loosening up the rules and processes to be followed, while at the same time tightening the control of results. Individuals, organizations, and systems are held accountable for the choices and decisions they make in this loose–tight arrangement—one that is loose about means, tight about ends.
In a political context, and most health-care systems find themselves in one to a greater or lesser degree, the purity of the management response can become contaminated by higher level political factors which cannot be ignored. So, even if it makes managerial sense to be tight about ends and loose about means, political reality may dictate the precise opposite, or may even result in abandoning the loose–tight distinction in favour of a tight–tight regime. Governments favouring a centralized, command-and-control system of policy-making and implementation, in order to deliver on their election promises and because they may genuinely, if somewhat naively, believe it is the way to effect change, are vulnerable to such distortions.
Management techniques amount to a bag of tools that managers should master and a range of competencies with which they need to be familiar to be effective. These include in no particular order:
communication skills (consultation, negotiation, and conflict management)
management by objectives
human resource management
economics, finance, and accounting
(strategic) planning and marketing
To be able to participate in needs assessment and issues concerning clinical effectiveness and health outcomes, which constitute a major component of the management challenge in health care, health-care managers also need knowledge about public health.
The setting in which the manager operates is made up of the physical infrastructure such as buildings and technology (especially information technology). These matters are beyond the scope of this chapter and are not considered further.
Models of management
There are four ‘world-views’, or doctrines, about the management of organizations (Moore 1996) as follows:
traditional bureaucracy—with an emphasis on clear structure, hierarchical chains of command, clear accountability for performance
new public management—with an emphasis on making organizations more like firms operating in markets through the introduction of competition to improve performance (Hood 1991)
‘Japanese’ organization model or ‘clan’—’solidarity’ model of organization in which a sense of identity with, and pride in, the organization itself is the main source of motivation
professionalism—shares the ‘Japanese’ model’s assumption that people work better when they are trusted and their performance is not closely monitored; the sense of identity is with the profession rather than with the organization, or possibly dual loyalty to both exists.
The central point about these world-views, or doctrines, is that management is not a purely technical enterprise. Ideas, culture, and ideologies make a real difference.
Within many health-care systems undergoing reform, there has been a shift from models of traditional bureaucracy and professionalism to a model of new public management where the emphasis is on encouraging public bureaucracies to mimic some of the ‘successful’ features of private sector management practices. These include government and public services steering more and rowing less, being mission-driven rather than rule bound, and being more responsive to the customer and to quality (Osborne and Gaebler 1993).
Although some of the competitive elements of new public management are out of favour with health-care reformers in the late 1990s who are talking the language of partnership and joined-up management, much of the ethos, and many of the principles, of new public management remain alive. For instance, the focus on managing for outcomes and on insisting that professionals be managed and held to account for their practices and the resources they consume continues to hold sway among policy-makers.
While elements of new public management thinking seem entirely appropriate for particular aspects of health-care activities, some commentators believe that it is misleading to regard it as a generic solution for every management design problem within the health sector or, indeed, elsewhere in the public sector (Stewart 1998; Hunter 1999). In particular, it is a mistake to overlook the professional nature of the majority of any health-care system’s work. Other management models may be more appropriate in the conduct of professional work. Later sections return to the limitations of a new public management approach in health care.
It cannot be said that a science or profession of management exists (see below) but a number of attributes can be identified which collectively attempt to define public management and its distinctive features. These are that it should
be close to the citizen and customer
be able to learn from a changing environment and apply that learning
be capable of using that learning to determine strategy and policy direction
work through political processes that steer management action
devolve responsibility and sharpen accountability
continually review performance.
Public management possessing these attributes is concerned with survival and with being adaptable. It stresses multiple objectives, teamwork, high trust relationships, and sharing information. It requires skilled managers who can operate appropriately in situations of extreme political uncertainty, ambiguity, and continuous change. Most health-care systems, and the function of public health within them, possess these features in abundance.
A key issue when considering management in a health-care context is the extent to which health-care organizations, whether publicly funded or not, and their management can be regarded as unique or at least different from other types of organizations, in particular from industrial or business organizations. Shortell and Kaluzny (1983) believe they are different and list the key differences as follows:
defining and measuring output are difficult
the work involved is felt to be more highly variable and complex than in other organizations
more of the work is of an emergency and non-deferrable nature
the work permits little tolerance for ambiguity or error
the work activities are highly interdependent, requiring a high degree of co-ordination among diverse professional groups
the work involves an extremely high degree of specialization
organizational participants are highly professional, and this primary loyalty belongs to the profession rather than to the organization
there exists little effective organizational or managerial control over the group most responsible for generating work and expenditure: clinicians
in many health-care organizations, particularly hospitals, there exist dual lines of authority, which create problems of co-ordination and accountability, and confusion of roles.
The uniqueness of health-care organizations can be overstated, especially if this implies that little can be done to improve managerial performance in the face of deep-seated and unique impediments. Yet, as Shortell and Kaluzny acknowledge, health-care organizations may at least be unusual, if not unique, in their possession of the above characteristics in combination: ‘It is the confluence of professional, technological, and task attributes that makes the management of health-care organizations particularly challenging’.
The independence of professionals from managerial control is less of a problem in situations where output is readily defined and measured. It is a rather different situation, as in health-care systems, when clear performance criteria do not exist and yet external bodies hold the organization responsible for the activities of the relatively independent group of professionals. Public health doctors stand somewhere in the middle of this complex of centripetal and centrifugal forces and are often placed in the position of trying to secure an effective accommodation between the requirements of the managerial domain on the one hand and those of the professional domain on the other. Indeed, it is this continuous struggle between these two domains which lies at the heart of successive reorganizations of health-care systems around the world, particularly those witnessed in European and Australasian countries over the past 10 years or so. This argument is developed further below in the light of the ‘cult of managerialism’ which has become a universal feature of virtually all health-care systems.
The managerial role
The literature on management is rich and diverse. A brief synopsis is offered of key developments in the conception of management and organizations. Classical theorists, such as Taylor (1911), viewed organizations in strictly rational, formal, and closed-system terms. They sought to formulate universal principles which would apply in all circumstances. These principles of scientific management consisted of:
programming the job
choosing the right person to match the job
training the person to do the job.
Weber (1978) took these rational principles further in terms of developing the ideal bureaucratic organization governed by a set of five clear rules and requirements:
the organization is guided by explicit specific procedures for governing activities
activities are distributed among office holders
offices are arranged in a hierarchical authority structure
candidates are selected on the basis of their technical competence
officials carry out their functions in an impersonal fashion.
The aim was to apply the rules in such a way as to ensure uniformity of practice and standards, and impersonality in the fair and equitable application of the rules and standards. Managerial initiative and creativity (sometimes referred to as entrepreneurial flair) were seen to be stifled by such rigidities. Moreover, the formal organization was seen as the ‘one best way’ to structure an organization and it made no allowance for the informal organization which existed alongside the formal organization and was often responsible for what actually happened in practice. Whereas the formal organization was regarded as rational and functional, the informal organization was seen as irrational and dysfunctional.
The closed-system rational model of organization with its principles of management has been powerful in terms of its influence on successive generations of managers and on writers about management. It still lies at the heart of some conceptions of operations research and management. While possessing severe limitations, which natural or organic system theories have challenged, most health-care organizations are organized and managed to some degree along bureaucratic lines. The natural or open-system approach developed as a reaction against the rigidities and other limitations of the rational, closed-system approach.
The rational model of management is based on three stages which are considered to be necessary in the realization of a rationally calculated decision:
the decision-maker considers all of the alternative courses of action that are open
her or she identifies and evaluates all of the consequences which would flow from the adoption of each alternative
he or she selects that alternative the public consequences of which would be preferable in terms of his or her most valued ends.
Above all, a rational decision entails clarity and agreement about goals and objectives, and a search for the best possible means of attaining them. The development, and application, of management techniques like cost–benefit analysis, programme planning budgeting, management by objectives, operational research, corporate planning, and zero-based budgeting illustrate the successive attempts by reformers to find ways to bring decision-making more in line with the rational model.
Although these and other techniques, usually offered by management consultants and economists, are intended to enable a rational choice to be made among a range of alternatives, in fact few of the techniques make an impact on actual decisions for the simple reason that the demands of rational analysis are in practice too great despite the sincerest efforts to achieve it.
A rational model, as Allison (1971) has suggested, presupposes the existence of a consensus within an organization among decision-makers. The greater the degree of rationality in a decision process, the greater the emphasis on consensus, harmony, a corporate approach to decision-making, and ‘technical’ criteria for the evaluation of proposals. Allison’s rational actor model sees choices in any field of decision-making as being clearly defined and based on rational assessments of public desires—it is merely a matter of fulfilling well-defined goals in an optimal manner. Decisions taken within the framework of the rational actor model reflect a single, coherent, and consistent set of calculations about particular problems. The possibility of organizational and political complications fouling the smooth-running machine simply do not enter into the model’s orbit, largely because rational models are normative and prescriptive rather than descriptive.
Although of limited value in illuminating how managers operate and decisions are taken, and although inclined to obscure rather than to reveal, an appreciation of rationality can provide further understanding of the management process. The structure of most organizations, including health-care systems, is largely derived from rational theories. Moreover, these theories underlie the public language in which politicians and policy-makers must argue and provide the legitimation of their bargains from whatever motives and interests these result. Similarly, managers may make decisions by doing deals but they would still be obliged to argue in the language of a rational model of the organization’s interests. Adherence to a rational paradigm remains strong, if only symbolically.
But, in the end, a rational model is flawed because it assumes a unitary view of organizational and managerial relationships and that all those making decisions identify with, and share in, a common superordinate goal. In the case of health services such a goal could be the welfare of patients. Tensions, or clashes of interest, between stakeholders are perceived as irrational and are defined as ‘technical’ problems—for example, a failure in communication, poor information, incomplete analysis, and so on. The unitary perspective denies the existence of sectional interests and is therefore unable to account for the activities and influence of such interests. To do so, a pluralist perspective is required which acknowledges the coexistence of various groups each with its own objectives and interests to pursue.
Not until the late 1950s did the balance begin to shift as a result of a series of studies which sought to focus rather more attention on possible impediments to the efficiency and effectiveness of management and organizational structures. Rational structures of decision-making and managerial control as the primary determinants of organizational life were challenged on the grounds that the empirical evidence from a variety of studies did not support this view of how organizations worked in practice. ‘Scientific management’ was shown to be severely defective in its explanatory power.
The growth and maturation of the social sciences in the late 1950s marked a new departure in organization and management studies. It was led by Crozier (1964), Simon (1957), March and Simon (1958), Burns and Stalker (1961), and Vickers (1968). These and other studies all attached importance to the existence of alternative systems of management, one appropriate to relatively stable technological and market conditions (the ‘mechanistic’ system of management articulated by Burns and Stalker), and the other to situations in which technology and market factors were changing fairly rapidly (the ‘organic’ system of management). They also demonstrated the importance of concepts like ‘bounded rationality’, ‘satisficing’, and ‘appreciative judgement’ in governing the actions of managers since there were cognitive limits on rationality which lead to the adoption of devices to assist the decision-making process. In the 1960s, an important book appeared—Psychiatric Ideologies and Institutions (Strauss et al.1964). This introduced the concept of ‘negotiated order’ within organizations whereby the various stakeholders in large psychiatric hospitals had quite different ideas about the appropriate management and care of patients. There had to be some accommodation among these and this was achieved through a process of negotiation. There was a recognition that organizations comprise disparate decentralized units in which the actors perform with different perspectives and priorities, and decisions are made by much pulling and hauling among them and not by a single rational choice.
In later studies of organization and management, the role of politics and power was seen as critically important in the achievement of goals (Bachrach and Baratz 1962, 1963, 1970; Pfeffer 1981, 1992). For Pfeffer, problems of implementation and management failure are ‘problems in developing political will and expertise—the desire to accomplish something, even against opposition, and the knowledge and skills that make it possible to do so’ (Pfeffer 1992). Accomplishing change in organizations requires more than an ability to solve technical or analytical problems. Because change threatens the status quo or a group of stakeholders (possibly more than one), it becomes essential to understand organizational politics if one is to manage change effectively and steer it in the desired direction. Pfeffer warns against ignoring the social realities of power and influence. Unless and until we come to terms with these, then organizational and managerial paralysis, that is, the failure to mobilize sufficient political support to take action, will become more evident. In place of implementing decisions, managers will spend endless amounts of time and energy on the decision-making process.
The concern with understanding organizational politics and power centred, as noted above, on the problem of implementation. Pressman and Wildavsky (1972), in a classic study of the issue, raised awareness of the importance of implementation as an area for study, especially in the context of policy-making. Implementation is not a passive process, faithfully enacting a policy. It inevitably reformulates the policy at the same time. Pfeffer (1992) argues that implementation is becoming more difficult because:
changing social norms and greater interdependence within organizations have made traditional, formal authority less effective than it once was
developing a common vision is increasingly difficult in organizations comprised of heterogeneous members.
Pfeffer maintains that managing power is an essential requirement in the achievement of desired goals. A number of steps are involved as follows (Pfeffer 1992).
Decide what your goals are, what you are trying to accomplish.
Diagnose patterns of dependence and interdependence: which individuals are influential and important in achieving your goal?
What are their points of view likely to be? How will they feel about what you are trying to do?
What are their power bases? Which of them is more influential in the decision?
What are your bases of power and influence? What bases of influence can you develop to gain more control over the situation?
Which of the various strategies and tactics for exercising power seem most appropriate and are likely to be effective, given the situation you confront?
Based on the above, choose a course of action to get something done.
These steps, and the whole issue of learning how to manage with power, are especially important in respect of public health when so much of what happens requires an ability to influence (not control) the behaviour of others, to change the course of events, to overcome resistance and non-compliance, and to get people to do things that they would not otherwise do. There are implications for the education and development of those working in public health which are taken up in the final section of this chapter. The converse is also true, namely the problems of performance and effectiveness are problems of power and politics—power imbalances, powerlessness, and the inability of some groups to get their ideas or suggestions taken seriously. These problems are likely to occur in the health-care settings in which performance outcomes are often difficult to assess, especially at the total organizational level, and in which results are likely to be long term.
Studies such as those mentioned above began to show how complex and variegated organizations are. Their management is similarly complex and multifaceted. Organizations were described as ambiguous, contained competing groups, subscribed to vague objectives, and appeared to be pursuing different goals simultaneously. In such settings, policies and decisions were not marked out through formal organizational and managerial structures but were agreed in ad hoc fashion through an unending process of discussion, bargaining, and negotiation between the relevant stakeholders. What occurs in practice in organizations can therefore best be described as a ‘continuous bargaining–learning process’ (Cyert and March 1963).
This convergence of studies of how organizations and managers operated in practice which appeared in the late 1950s and early 1960s was eclipsed through the 1970s and 1980s, although may be making a comeback at the start of the 21st century. Whereas there had been a drawing away from the conception of organization and management embodied in scientific management or Weberian bureaucracy, with important exceptions, like Mintzberg’s studies of managerial work, the 1970s and 1980s saw a rekindling of interest in the principles of bureaucracy and scientific management.
As the earlier discussion in this section demonstrated, the management structure of industrial and business organizations was held up as a model for public sector services, like health, to adopt and, in extreme instances, mimic. Simplistic, almost naive notions about how organizations functioned pervaded the ‘new rationalism’ which permeated government in the United Kingdom and elsewhere from the 1970s on. Such notions were to some extent a reaction against the studies of organizations which sought to demonstrate how diverse, pluralistic, and multilayered they in fact were. But insights of this type were uncomfortable and unsettling for managers and policy-makers intent on the achievement of clear goals and objectives. The undermining of the scientific management school of thought with its comfortable certainties about the nature of organization and management was bound to result in a backlash and a nostalgic harking back to a simpler explanation. This may largely be responsible for what Burns (1994) has called ‘the recrudescence of the hard-line managerialism which has manifested itself in recent years first in America and then in Britain and Europe’. This hard-line managerialism has been to the fore in health-care reform in developed countries in recent years. Developing countries are being attracted to similar solutions (Collins et al. 1994). These issues are explored further in the next section following a summary of the argument so far.
If health-care management cannot be said to be unique, although contingency theorists might argue that it is, there is no disputing its distinctiveness or the differences it displays. But there is no general all-purpose science of management. Nevertheless, certain theories and concepts over the years have influenced in powerful ways the conception and practice of management. In particular, the theory of scientific management, and related notions of rational decision-making, have been a major influence on the design of management systems. The weakness of scientific management lies in the evidence that managers in practice do not behave according to the theory. To understand how they operate it is necessary to turn to the behavioural sciences and to apply concepts like politics, power, and bargaining. These have revolutionized the understanding of management and the context in which managers operate. Yet, rational theories of management continue to inform the public face of management. They legitimize actions even if they are not the primary determinants of them.
The new rationalism and health
As mentioned above, during the 1970s, a ‘cult of managerialism’, which remains evident some 30 years later, swept through government in a number of countries. It was directed towards improving the performance of public services which were seen to be overadministered and undermanaged. Allegedly, public services like health had weakly articulated goals and, where they existed, ineffective means of achieving them. The industrial and business sector was used as a source of ideas and practical ways forward. There was also a new-found enthusiasm for the mechanistic and rationalistic approaches to management which had been discredited in the 1960s by studies of how organizations and managers in fact operated. Notions of comprehensive rational planning and command and control mechanisms for running organizations were prevalent in the 1970s as politicians wrestled to contain public expenditure and improve the performance of public services. The 1974 reorganization of the British NHS was a model example of these concepts and ideas being put into practice on a grand scale (Hunter 1980).
By the 1980s, the political climate had shifted dramatically. Not only were public services being accused of poor management but their very existence was being challenged. The prevailing political ideology was unequivocal in its opposition to monopoly public services and actively sought ways of privatizing them, or parts of them, as a means of containing costs and improving performance through the principle of competition and markets.
These developments have been described by Hood (1991) as constituting ‘the new public management’. As a movement, the new public management has caught the imagination of governments worldwide. It constitutes a kind of managerial pandemic reinforced by the World Bank’s endorsement of it (World Bank 1993). The new public management, argued Hood, ‘is one of the most striking international trends in public administration’ (Hood 1991). Its rise is linked with four other administrative trends occurring at the same time:
attempts to slow down or reverse government growth in public spending
the shift towards privatization and quasi-privatization and away from core government institutions
the development of automation, particularly in information technology, in the production and distribution of public services
the development of a more international agenda, increasingly focused on general issues of public management, policy design, decision styles, and intergovernmental co-operation.
New public management, as Hood describes it, is a loose shorthand label for a set of broadly similar doctrines which dominated the management reform agenda in many of the Organization for Economic Co-operation and Development countries from the late 1970s (Pollitt 1990). It sought to replace ‘old’ public management which, with its complex bureaucratic structures and centralizing ethos, had failed spectacularly to improve the performance of services. Some observers saw new public management as nothing more than ‘a gratuitous and philistine destruction of more than a century’s work in developing a distinctive public service ethic and culture’ (Hood 1991). Moreover, a contradiction was seen to lie at the heart of new public management thinking. Despite talk of the need for innovation and flexibility, this was to be relieved through a series of instruments, notably purchaser–provider separations, contracts, and targets, all of which are more than capable of limiting both innovation and flexibility (Stewart 1998).
New public management has seven doctrinal components (adapted from Hood (1991)):
hands-on professional management in the public sector
standard setting, performance measurement, and target setting, particularly where professionals are involved
emphasis on output controls linked to resource allocation
the disaggregation or ‘unbundling’ of previously monolithic units into provider/producer functions, and the introduction of contracting
the shift to competition as the key to cutting costs and raising standards
stress on private-sector management style and a move away from the public service ethic—this includes the introduction of marketing and public relations techniques
discipline and parsimony in resource use—cost cutting, doing more with less, controlling labour union demands.
New public management derived its theoretical origins from two sources: the new institutional economics and business-type managerialism. The former helped to generate a set of related reform doctrines built on notions of contestability, user choice, transparency, and incentive structures. Such doctrines were markedly different from traditional notions with their emphasis on orderly hierarchies and the elimination of overlap. The business-type managerialism was merely the latest in a succession of waves of this type which began in the 1970s and were described earlier. It was in the tradition of the scientific management movement, also described above, although it underwent a facelift and image change, and in the process acquired a new jargon. Central to this type of managerialism was a set of common beliefs: professional management (a) was generic and portable, (b) was paramount over technical expertise, (c) required high discretionary power to achieve results, and (d) was central and indispensable to better organizational performance.
There is no single accepted explanation for the considerable appeal of new public management. It would appear to be a response to global socio-economic changes with an abhorrence of ‘statist’ and uniform approaches in public policy and a perception that public services seem to be run more for the convenience of those providing them rather than those paying for and using them. Part of the appeal is that it cuts across party lines and can be seen to be politically neutral.
An emphasis on health sector reform adopting a particular managerial approach based on new public management principles has been encouraged by the World Bank (1993). The thrust of the World Bank’s approach has been to promote diversity and competition. A system of ‘managed competition’ is seen to offer a number of advantages although its limitations and disadvantages are acknowledged in passing. Managed competition or care pursues cost-effective health spending, universal insurance coverage, and cost containment through tightly regulated competition among companies that provide a specified package of health care for a fixed annual fee. Evaluations of it show mixed results but Light (1994, 1999) regards competing managed care systems as unlikely to tackle the great health-care needs of the twenty-first century and the diseases of chronicity and preventable morbidities.
The World Bank claims that the encouragement of competition in the delivery of health services coupled with effective regulation would increase the effectiveness of health spending. But would it? The transaction costs associated with competitive systems are high and may outweigh any benefits which may be forthcoming (Evans 1997). The evidence that competition in health care leads to gains that are not eliminated by other factors does not exist (Maynard 1993).
Growing concern among centre-left governments elected in the latter half of the 1990s that the application of market-style mechanisms may have resulted in various dysfunctional aspects in organizational design and management practice, notably greater fragmentation and rising management costs, have resulted in new waves of reform aimed at acknowledging that connected problems require ‘joined-up’ solutions. Therefore, and this is crucial, without abandoning all aspects of new public management thinking, governments have sought to modify some of its market-style features. Arguably, this has given rise to emerging tensions over the style of management that is most appropriate for the health-care enterprise.
Critics of new public management accuse it of being all hype and no substance (Rhodes 1995; Stewart 1998). Scratch away the trendy jargon and fashionable packaging and a fairly orthodox approach to management is all too evident. The language spoken may have changed but beneath it all the old problems and weaknesses remain. Other critics claim that new public management has simply led to a rapid growth of managers without evidence of effectiveness in terms either of lowering costs or improving health.
Wider criticisms of new public management centre on the inappropriate importation of business sector practices into a public service culture. In particular, especially in health care, notions of competition and markets are viewed as anathema and as ultimately leading to the destruction of a public service ethos. The idea that a pure market is possible in health care is akin to the naivety of those who subscribe to the ‘scientific management’ school of thought with its simplistic beliefs about rationality and human behaviour. Understanding how markets actually work and the concept of market failure echo the work on ‘negotiated order’ by Strauss et al. (1964) described above. If organizations are political constructs in which various interests jostle for supremacy, then markets can be similarly manipulated and subject to the interplay of power between stakeholders. Managers, therefore, need to understand the nature of organizations from such a behavioural perspective if they are going to succeed in moving them closer to agreed goals.
As Handy (1994) has written, ‘the acceptance of paradox as a feature of our life is the first step towards living with it and managing it’. Whereas Handy, rather like Taylor and his theory of ‘scientific management’, and Weber with his theory of ‘rational bureaucracy’, used to think that paradoxes were the visible signs of an imperfect world which demanded to be eradicated, he no longer believes in the possibility of perfection: ‘Paradox I now see to be inevitable, endemic and perpetual. The more turbulent the time, the more complex the world, the more the paradoxes’ (Handy 1994). While it may be possible and desirable to minimize the inconsistencies and understand the puzzles in the paradoxes it is not possible to solve them completely. In the final analysis, ‘paradoxes are like the weather, something to be lived with, not solved, the worst aspects mitigated, the best enjoyed and used as clues to the way forward. Paradox has to be accepted, coped with and made sense of …’ (Handy 1994). It does not have to be resolved—only managed.
What does this mean for managing and planning for health? The buzz-words in the management literature, many of them far from new but dusted down because they resonate with the spirit of the times, are complexity, paradox, ambiguity, and uncertainty. Chaos theory and complexity science have replaced comprehensive rational theory as offering more accurate explanations of how the management task has changed and of what is required to achieve sustainable change (Zimmerman 1999). Successful organizations and managers live with paradox. Organizations have to be planned and yet remain flexible, be differentiated and integrated at the same time, be small in some ways but large in others, be centralized some of the time and decentralized for most of it. Whereas managers used to believe that their task was to choose between such opposites, the task is in fact one of reaching an accommodation between them. It is all a matter of balance and of constantly adjusting and fine-tuning it.
Organic open systems of management, which Burns and Stalker (1961) and others wrote about in the early 1960s, were back in vogue in the late 1990s, albeit sitting uneasily alongside notions of new public management which remained popular. However, the terms post-Fordist, postbureaucratic, and postmodernist are used to distinguish such forms from their mechanistic counterparts described by Taylor and Weber (Hoggett 1991). In Handy’s words (Handy 1994):
The organisations of the future may not be readily recognisable as such. When intelligence is the primary asset the organisation becomes more like a collection of project groups, some fairly permanent, some temporary, some in alliance with other parties.
In such a context there are clear limits to management—it is not a panacea for organizational pathologies and social ills. It is possible that we are living through a time called the edge of chaos—a time of turbulence, creativity, and transition out of which a new order may materialize and gel.
Management: science or liberal art?
As a consequence of the foregoing distillation of theories of organization and management over the past 90 years or so, it is hardly surprising that establishing an integrated management ‘science’ in the conventional sense is regarded as highly improbable (Whitley 1988). The low degree of standardization of intellectual objects and concepts in the management sciences is exacerbated by the difficulty in separating them from managerial practices. Management researchers, as Whitley affirms, have not been able to isolate general phenomena and processes which could reasonably be claimed to underlie managerial practices. As the preceding discussion has demonstrated, this is a reflection of ‘the necessarily contingent, contextual and relatively unstable nature of managerial tasks and activities’ (Whitley 1988). It is a conclusion shared by Kotter (1982) in his study of 15 general managers. He states that the data from his sample show a complexity ‘which often makes many managerial textbook concepts seem woefully inadequate’. Even the general managers themselves had difficulty understanding the level of complexity. Management at this senior level looks far more like an art than a science although patterns of behaviour can be discerned.
Management is not independent of the phenomena it seeks to control, influence, or manipulate. It is in fact part of these phenomena. Indeed, these phenomena largely shape and define management and the particular management style adopted. When these get out of step and lack congruence, as may be happening in health-care services where a particular conception of management borrowed from the industrial sector is overlaid on to a professional organization, then cognitive dissonance is likely to occur as well as attempts to temper that particular management style (Lloyd et al. 1999). To this extent, management is a dynamic activity able to adapt to its environment. Where management cannot adapt, it is likely to be recast or overturned through a reorganization, or through a series of individual acts against particular managers.
Drucker (1990) claims that management is a liberal art:
‘liberal’ because it deals with the fundamentals of knowledge, self-knowledge, wisdom, and leadership, ‘art’ because it is practice and application. Managers draw on all the knowledge and insights of the humanities and the social sciences.
For this reason, management cannot be called a science. For Drucker, because management deals with people and their values, it is a humanity.
In short, management is not a distinct activity or function which can be studied in isolation from the context in which it occurs. The notion of a generic management which can be applied to any organizational setting is therefore suspect and ignores the subtle interaction between management and its particular locus. Standardized skills of the type to be found in medicine and law, and other professions, do not exist and therefore are not subject to ‘scientification’. Attempts to establish a general ‘science of managing’ are doomed to failure since managing is not a standardized activity but is highly context-specific. As Kotter (1982) argues:
if ‘professional management’ means the ability to manage nearly anything well by relying on universal principles and skills and not on detailed knowledge of the specific business involved and close relationships with specific people involved in that business, then not one of the effective executives in this study was a ‘professional manager’.
Nor did Kotter’s managers operate in a well-organized, proactive, and reflective way. Yet their seeming ‘irrationality’ and disorganization worked.
Planning for health
Notions of planning and strategy have mostly tended to follow management fads and fashions. So, in the 1960s and 1970s when concepts of management tended to be of the command-and-control top-down variety, concepts of planning were similarly of a centralized, synoptic rationality type. The subsequent failure of comprehensive rational planning was accounted for by its adherence to a definition of comprehensiveness in a world that lacks any comprehensive political power or institutions. In challenging the somewhat mechanistic and simplistic view of strategy underpinning comprehensive rational planning, Mintzberg’s (1990) notion of strategy as a result of a myriad of decisions and not the logical or inevitable outcome of economic and technical rationality is akin to the bureaucratic politics view of organizational life most ably illuminated by Allison (1971). Mintzberg (1988) defines strategy as what organizations actually achieve and not just what they intend to achieve: ‘Defining strategy as a plan in advance of taking action is not sufficient’.
In understanding health planning it is therefore necessary to move away from the corporate planning models prevalent in the 1960s and 1970s in a number of countries, with their emphasis on synoptic rationality, and to look at what managers actually do by way of planning. A distinction, paralleling ‘closed’ and ‘open’ systems of management, can be made between planned strategy on the one hand and emergent strategy on the other. McKevitt (1992) describes the distinction as follows:
Planned strategy emphasises direction and control of the organisation and it is thus more suited to a predictable external environment. Emergent strategy … puts the emphasis on organisational learning whereby corrective action can be taken to alter strategic direction and to experiment, adapt and review the original decision in the context of changing circumstances.
Arguably, it was the failure of the rational comprehensive model of planning prevalent in many health-care systems that led to widespread disillusionment with health planning of any description and eventually to the various reform moves in the 1980s and into the 1990s with their emphasis on decentralized market-type solutions.
Public health was directly involved in these various developments since the notion of planning, whatever interpretation of it was adopted, was seen as essential in addressing the dilemma of rising demand for health care coupled with finite resources. Some form of priority-setting that was transparent and equitable was regarded as essential. Through the 1970s and early 1980s, planners, many of them with a public health qualification, struggled to develop a robust planning framework for health services. Their efforts were always doomed to failure because, rather like the adherents to the theory of ‘scientific management’, they failed (or forgot) to acknowledge that to secure effective change it is necessary to acquire ownership for it from those affected by it. It cannot be imposed from above, at least not if it is to be implemented successfully.
For Barnard (1991), the failure of rational central planning in the British NHS paved the way for ‘the school of thought which in many countries enjoyed ascendancy during the past decade [with its] reaffirmation of the superiority of markets and price mechanisms as the means of satisfying human wants’. Managed competition and devolved management replaced the corporate rationalist approach. The health-care reforms of the 1970s were seen to be overly cumbersome and bureaucratic, and to belong to an outmoded rationalist tradition based on Taylorism and his theory of ‘scientific management’. Failure, in Barnard’s (1977) view, was virtually guaranteed since
there is no simple product or range of products in the health service which would allow rationalization in the interests of efficiency
consumer behaviour is difficult to understand in the health-care context
conflicting local interests make consultation and collaboration laborious
the dominant feature of health-care delivery is one which involves concentrating on relieving present problems and not on the provision or attainment of a desirable state of affairs some time in the future, that is, ‘the urgent’ forever drives out ‘the important’.
Many of these factors remain current. Rathwell (1987) concludes his study of strategic planning in the British NHS by cataloguing the reasons for its failure. Chief among these is the separation between management and planning. There is a failure to connect the two. As a consequence, planning is viewed as a highly prescriptive function not keyed into the real world. Management is in practice little more than administration.
With the move in many countries in the late 1980s and early 1990s towards notions of managed markets and a separation of purchaser–provider responsibilities to permit the creation of competition, the planning function passed to the purchaser organization. The separation of roles was seen as desirable because, whereas planners in integrated organizations had been regarded as victims of provider capture, under the new arrangements operational responsibilities would pass to providers leaving purchasers free to think and act strategically. The greater clarity of functions was heralded as an important opportunity for public health because its skills would be central to the purchasing task. The emphasis on health gain and the need to demonstrate that medical investments were effective in improving health status gave public health a new lease on life. But the difficulties arising from making the purchaser–provider split work, and the long-term nature of issues associated with effectiveness and outcomes, have rather blunted public health’s ability to make a significant impact. However, before pursuing these matters in the context of equipping public health practitioners with appropriate management skills, it is necessary first to reflect upon the nature of management in public health. Before doing so, a summary of the discussion thus far is in order.
The purpose of this section has been to describe in general terms the evolution of theories of management, planning, and organization and to show how these have impacted upon public management and health-care services. In offering this overview of developments in management, it can be seen that a general science of management is not possible or meaningful because the practice of management cannot be isolated from the context in which it is practised.
The next section adopts a narrower focus and, on the basis of the above discussion on evolving notions of management, examines the specific relationship between management, planning, and public health, and the application of management and planning to public health.
Management and public health
Biomedical systems operate very differently from management systems and are able to subscribe to scientific principles of thought and action, and cause and effect. Perhaps it is their training for this world which makes clinicians, including public health specialists, ill-equipped for a management role, especially of the type studied by Kotter (1982), and described in the previous section. Whereas they may be searching illusively for an understanding of their managerial role rooted in a science of management, in fact what is required is a quite different conception of the management task. Unlike medicine, the nature of managerial skills is not clearly established, nor are they standardized to the same extent. Practitioner-controlled knowledge does not exist in management as it does in medicine. As has been shown in the preceding discussion concerning changing theories and conceptions of management, managerial skills deal with much more variable, contingent, and unstable phenomena which include managerial practices themselves. Management’s interdependence with the very realities it is seeking to control or influence shapes it.
The tension between bureaucratic and professional models of control is mentioned in the introduction. In the last section, attempts to subdue professional autonomy, if not curtail it, through managerial reform are described. The history of health-care reform globally has been one marked by border skirmishes between managers and professions, notably the medical profession. At the core of the management revolution in health care has been the view that doctors must increasingly accept managerial responsibility as well as be managed themselves by non-medical professional managers. In the United Kingdom, the arrival of general management in 1984 heralded a new era of difficult relations between the medical profession and the new breed of general managers. No longer is the medical profession responsible for what happens, and does not happen, in health policy. Bureaucratic politics have eroded the medical profession’s authority (Morone 1993).
It seems that Sir Roy Griffiths, architect of general management in the NHS, was not altogether happy with this outcome. As he argued in a lecture 7 years after the introduction of general management, he never intended his report to be confrontational with the professions (Griffiths 1991). He understood general management ‘as shorthand for the introduction of an effective management process. I did not intend that the result should be yet another profession in the NHS to work in parallel with other professions’.
Even in America, the land of market-led medicine, the medical profession’s freedom is strictly curtailed through a variety of management decrees and controls. As Morone puts it, ‘control over health policy had passed from providers and legislators to the health bureaucracy’ (Morone 1993). The managed care movement has evolved to monitor in detail the ways in which doctors operate. What was once deemed specialized knowledge is now subject to protocols and guidelines. Professional models of organization are progressively being transformed into managerial ones. The micromanagement of medical work is in evidence in many health-care systems in Europe and Australasia. It is occurring through an emphasis on evidence-based medicine and on concepts like clinical governance which are intended to improve clinicians’ performance by encouraging them to manage their work more effectively. Much of the thinking underlying clinical government includes managerial notions like leadership, creating development plans, clarifying accountability, and so on. These various developments have led to intense debate among sociologists about the extent to which medicine has become ‘deprofessionalized’ and ‘proletarianized’ (Hafferty and McKinlay 1993).
Public health specialists occupy a halfway position between the worlds of management and professionalism. They are therefore partially exempt from the power play between medicine and management because they subscribe to a population-based approach to health care and are generally more sympathetic than many of their clinical colleagues to a managerial perspective on matters like planning and priority-setting. For their part, managers are generally more concerned about the collective, that is, about the total population within a locality, and the principle of solidarity.
But if the frontier between medicine and management is shifting perceptibly towards managers as a result of health systems reforms, and related developments in the areas of medical audit and clinical effectiveness, does this not work to the advantage of public health and those who practise it? Or do public health specialists feel threatened by, or oppose, the tighter managerial grip on the grounds that it can operate to compromise their independence and freedom as professionals to speak out and can exert inappropriate pressure to produce quick results (Griffiths and Hunter 1999)?
The specialty of public health medicine is itself ambivalent in its response to these questions. Indeed, there are clear divisions of opinion between those who believe public health must be an active part of the management system with a place at the top table and those who wish public health to remain detached in order to preserve its independence and professional integrity.
Part of the dilemma for public health and its uneasy relationship with management may lie in the model of management which many health-care systems have imported, and only marginally adapted, from the industrial and business sector. As mentioned in the previous section, recent years in virtually all areas of public policy have witnessed a recrudescence of hard-line managerialism. It runs counter to professional conceptions of management which have more in common with post-Fordist notions. These are now fashionable and may offer a means of resolving the tension between bureaucratic and professional models of managerial control. Rather than polarizing these which recent health systems reforms have tended to do, unintentionally or not, the issue may in fact be one of finding a new synthesis in which traditional collegiate forms of professional organization are in fact precisely those needed in order to achieve team working, initiative, and collaboration among a range of diverse skills on the basis that complex problems demand complex solutions (Hunter 1999). As Handy (1994) puts it, ‘organizations will be flatter, more flexible and more dispersed’. More importantly, he continues:
The old language of management no longer seems appropriate. It never was appropriate in some quarters. Professional organisations, doctors, architects, lawyers, academics have never used the word manager, except to apply it to the more routine service functions—the office-manager, catering-manager. The reason was not just a perverse snobbery but an instinctive recognition that professionals have always worked on the principle of the doughnut. This was necessary because every assignment was slightly different; flexibility and discretion had to be built in.
The doughnut principle (see Handy 1994) requires an inside-out doughnut, one with the hole on the outside and the dough in the middle. Organizations have realized that they have their essential core, a core of necessary jobs and necessary people, a core which is surrounded by an open flexible space which they fill with flexible workers and flexible supply contracts. The strategic issue for organizations is to decide what activities and which people to put in which space.
Arguably, public health has been derailed because it has been forced to conform to an inappropriate ‘scientific management’ model whereas in fact its own professional instincts might have served it better had it not had to conform to a mechanistic model of management—the ‘old’ management imported from much, though by no means all, of the business sector, and some of which lingers under the guise of new public management. Yet, public health’s roots in a scientific medical model of health and disease may have contributed to the dilemma confronting it. Though severely limited in its ability to describe or modify organizational life, scientific management at least resonated with the scientific tradition underpinning public health medicine from which it derived its legitimacy and credibility. Behavioural approaches to management sit uneasily with the scientific tradition. While the ‘new’ (public) management (see above) with its emphasis on outcomes may come closer to public health’s concerns, its simultaneous focus on markets and individuals as consumers runs counter to public health’s values and responsibilities.
A new managerial paradigm
Public health has flirted with management and in its innocence has been drawn to an inappropriate model which negates the intrinsic strengths of the specialty itself. These strengths derive from its roots in the profession of medicine. In this and other professions, collegiate forms of working operate in place of hierarchy and rigid levels of management. In such a context management is founded on trust whereas the managerialism prevalent in many health services in recent years, and evident in much new public management thinking, is founded on distrust. Performance management is centred on providing proof of performance and on individuals and organizations answering for what they fail to do. Concepts like ‘chain of command’ and ‘centralization versus decentralization’ are essentially about exercising control.
In contrast with these mechanistic notions, network structures represent a paradigm shift and derive from the flatter doughnut-configured organizations which have emerged in the 1990s. Flexible organic structures look set to replace rigid, inflexible bureaucratic structures. Given the rapid pace of change, the revolution in knowledge and its transmission via the information superhighway, organizational structures which are not extremely adaptable and open to the environment will simply not survive. Structures, and the management systems operating them, will need to be more transitory and ad hoc at all levels—operational, strategic, and administrative (Mintzberg 1980).
Network organizations, which function according to the doughnut principle in so far as they possess a central core surrounded by a constellation of project teams which exist for the duration of particular tasks and are then reformed, will survive. Such structures are flexible and fast moving because they can change quickly as the environment changes. They can also better tap external expertise and knowledge rather than attempt to provide it all in-house.
Without seeing the disappearance entirely of the traditional bureaucratic type of organization in health services, it is likely that network organizational structures will become more widespread. Developments in health services such as the purchaser–provider separation, management by contract, managed competition, integrated care/clinical pathways, and so on, will most likely encourage the network organization. The idea is not especially new. Writing in the early 1970s about the loss of the stable state and about what might replace it, Schon (1973) defined the roles of the network manager. Such a person was required in order to allow organizations to be continually redesigned ‘without flying apart at the seams’ (Schon 1973).
In network organizations a new set of roles becomes necessary. They are essential to the design, creation, negotiation, and management of networks. Schon (1973) identifies six roles:
‘underground’ manager—maintains and operates informal networks
manoeuvrer—operates on a project basis
network manager—oversees official networks of activities
These roles are difficult and demand high personal credibility for their successful execution. They are often performed by those who exist on the margins of organizations. As will be suggested in the next section, public health’s management function is perhaps best understood by drawing parallels between the expectations of it and the notion of network management described by Schon.
If there is a congruence between the new managerial paradigm described above which is emerging in public services like health care and professional forms of organization, then public health may, or could, be at the leading edge of developments in management. In reshaping the management roles they assume, public health specialists are in fact part of a broader shift taking place in the nature and definition of management in health care. From attempts in the 1970s, 1980s, and early 1990s to strengthen management in order to control professionals, there is evidence of a shift towards different managerial forms in which professionals potentially have a great deal to offer. This movement seems wholly in keeping with the general management function as Griffiths perceived it in his 1991 Audit Commission lecture (Griffiths 1991).
The tension between bureaucratic and professional models of control lies at the core of public health’s uneasy relationship with management. Arguably, it may not be management per se which is the problem but rather the type of management to which public health is expected to confirm or contribute. At the same time, notions of management with a behavioural bias can pose problems for a discipline whose origins lie in a scientific rational model of disease and illness. Yet, of all those practising medicine, only public health specialists appear to be pivotally placed to marry professional collegiate forms of managing with network management. But before this can happen, public health needs to rid itself of the clutter of outmoded and inappropriate management constructs which have tended to limit its impact over the past 20 years or so. It also needs to acknowledge the importance of a public health management role.
Perhaps the future lies in a synthesis of public health’s traditional professional ethos combined with a grounding in the newer, emerging notions of management. Such a synthesis may be termed public health management. The next and final section considers what is understood by public health management and how it can be brought to life.
Public health and management: towards a synthesis
Improving the health of populations is a challenge confronting all countries in both the developed and developing worlds. Health-care reform has been a catalyst in the long-running debate about how best to improve health because of a renewed emphasis on health as distinct from health care. The twin specialisms, or professions, at the centre of these concerns are public health and management.
As health care has become more complex a false antithesis has emerged between public health and health services management. Whereas public health specialists have generally looked outwards towards society and the health needs of the population, health services managers have tended to focus inwards on the organization, and particularly on the financially demanding secondary and tertiary care sectors. The shift towards a primary-care-led health-care delivery system is forcing a rethink. At the same time, many public health practitioners believe that they have become overidentified with health-care services. Indeed, this dilemma has become more acute with the growing emphasis on clinical governance and evidence-based medicine all of which appear fairly dependent on public health practitioner involvement (Wylie et al. 1999).
The notion of public health management is an attempt to bring together public health’s planning and management skills but to give them a higher profile and recast them in the light of the discussion in preceding sections on the changing conceptions of management and planning. The concept involves mobilizing society’s resources, including the specific resources of the health service sector, to improve the health of populations (Alderslade and Hunter 1992, 1994; Hunter 1993; Richardson et al. 1994; Hunter 1998).
The objective of health improvement has a long history among public health practitioners. The discipline of public health medicine has had twin intellectual approaches—knowledge and action—which have gone together. In practice, there has been a tension between knowledge and action, with many practitioners in public health focusing on knowledge rather than action. Public health management seeks to integrate the two approaches so that public health knowledge can be harnessed to action through the deployment of appropriate management and planning skills. These skills are rooted in an open systems approach to management, drawing on related notions of negotiated order and network management described above.
To this end, public health management demands skills other than those generally to be found in public health. Those working in today’s public health function are expected to respond to the multisectoral nature of health problems and serve a variety of agencies. Working in a multisectoral arena to develop healthy alliances is akin to the marginal position desired by network managers and discussed by Schon (1973).
These are heavy demands requiring well-honed political and managerial skills in addition to the traditional scientific skills associated with public health. It is a particularly difficult synthesis to achieve not because of the range of skills required but because they come from two quite distinct paradigms. The traditional basis of public health medicine belongs to the positivist biomedical view of scientific enquiry, whereas the political and managerial skills base comes from an intuitive contextual orientation grounded in how organizations work. The tradition is sociological and anthropological rather than biomedical. This may explain why public health specialists often find ‘scientific management’ theories more immediately appealing than theories of a less ‘rational’ and more behavioural persuasion where uncertainty, complexity, paradox, and ambiguity figure prominently.
Public health management is, like public health itself, a multidisciplinary activity. Clear implications flow from this for the direction and type of training in public health medicine and in related areas which have a public health focus.
There is a need for public health doctors, non-medical public health specialists, and managers to find an intellectual focus for joint working since each group has a vital contribution to make to the superordinate goal of improved health. Failure to find this can only result in further interprofessional rivalry and a lack of co-ordinated working. Public health management demands knowledge and management skills of the highest order. Public health managers must be able to adopt a strategic approach and be able to describe and understand the health experience of populations and analyse the factors affecting health. To achieve change, skills in leadership and political action are necessary; managers have to operate in a multiprofessional multiagency environment and be able to achieve multisectoral change. Operating on the margins of their own organizations becomes a prerequisite.
In taking forward this multisectoral approach and health agenda, a number of key processes are involved:
building alliances and networks with non-health service organizations; relationships will be based on influence rather than on direction and control
market management: having a strategic framework based on health improvement, the capacity to work within alliances, possessing good market-relevant information
attention needs to be given to organizational fitness for purpose; it means moving away from functional departments and towards a blending of skills in task forces and in project-managed initiatives—such a team approach will be looser and more fluid than conventional functional departments with their often lengthy hierarchies and multiple layers of management.
Moving forward in respect of these processes has implications for management training and development for practitioners of public health management. Certain competencies and qualities are critical although little empirical work has been carried out to identify these in practice-based contexts. An Australian study (Lloyd 1994) identified ‘key figure’ attributes for the effective public health manager as being the following:
charisma, commitment, drive, and an ability to function in a loosely regulated environment while at the same time dealing with bureaucratic processes.
These qualities are regarded as central in attempts to foster fundamental change in the direction of health services towards measurable health gain. There is growing acceptance of the need for political and management skills. A former Chief Medical Office in England, Sir Kenneth Calman, believes that (Calman 1993):
The practical implications of public health are an art and require special skills in themselves. Skills need emphasising and include both management and political skills in the communication of ideas and complex public health issues.
Developing the catalogue of competencies further, Lloyd (1994) reports on the need for competencies relevant to the leadership of complex work groups—communication skills, interpersonal skills, understanding of organizational behaviour, intellect, analytical skills, planning skills, accounting skills, and an understanding of how the system works.
Management education has been a perennial issue for public health. But it needs to be less concerned with theoretical approaches and the prevailing bureaucratic and economic rationalist model of health management and focused instead on social organization, behavioural approaches, and interpersonal skills. This type of management training is weak or non-existent and yet, as can be seen from the preceding sections of this chapter, it is crucial. A frequent criticism of management training for public health doctors has been its largely mechanistic nature. Curricula have mostly remained rooted in conventional approaches and management practices applicable to operating in a bureaucratic organization, or in administrative practices, and in a mainly theoretical approach to management. They are based, not surprisingly, on conservative individualistic principles and reflect the ideology of scientific reductionism emphasizing such activities as organizational delegation, industrial-style negotiation, policy interpretation, and information dissemination. Such processes tend to assume and reinforce the established tradition of élitist management and top-down hierarchical control. As Lloyd (1994) concludes:
It reflects a fundamentally authoritarian, and hence limited, appreciation of what the management role can encompass, as well as having minimal significance in terms of influencing the health of the population.
In contrast, the challenges posed by the new public health demand an approach to management education that emphasizes the dynamic dimension of the learning organization and of managing change (Forster et al. 1994). Management principles derived from conventional health bureaucracies are no longer relevant or appropriate. With organizations being re-engineered, delayered, and right-sized, they are flatter. Managers achieve results through enabling, facilitating, and delegating and not through an exclusive or predominant focus on top-down hierarchical command-and-control mechanisms. They need to work in teams and across professional and organizational boundaries. As an American management expert on leadership, Bennis, has put it, great achievements, particularly in the complex modern world, can only be collective: ‘none of us is as smart as all of us’ (Bennis 1998). The competencies needed for team work centre on building networks and deploying political skills such as networking and manoeuvring to maximize the influence that can be brought to bear on a given problem.
Thompson (1990) makes a similar case when he argues that students of health-care management are not being adequately equipped with a comprehensive range of knowledge and the skills to apply it to real problems. He laments the failure of organization and management research to influence the direction of management (Hunter 1988). The impact of most of the findings from management research appear to be on management itself but not on the community being served and how management affects it.
The rise of management in health-care systems is a global phenomenon and has been much in evidence over the past 25 years or so. Central to all managerial reforms has been a technocratic faith in improved management and in its capacity to resolve deep-seated, and essentially political, problems. A principal feature of the evolution of management in health-care systems has been the struggle between doctors and managers, whether played out overtly or covertly.
The so-called ‘new rationalism’ of the 1970s and early 1980s has re-emerged in a new guise in the 1990s, albeit with a slightly different focus. This is known as the ‘new public management’ and it is largely a reaction to the perceived failures of what might be called old public management or a traditional public administration approach to public sector management. Part of the search for different management models was fuelled by a loss of faith in comprehensive, or synoptic, rational planning led from central government.
But whatever the perceived failures of old public management, new public management is also flawed. In particular, markets and medicine do not mix well. Markets are of limited utility in health-care systems governed by principles of:
equity or social justice
access to care at time of need
Market failure cannot be dismissed as being of no consequence. Even the World Bank, a supporter of markets, acknowledges this. However, although new public management may not offer a wholly satisfactory or stable basis for managing health care, its disciplines have, possibly unwittingly, loosened up sclerotic structures and conventions and paved the way for a possible paradigm shift in respect of how health policy and management is conceived of and conducted. Public health is critical to these developments but the training for it will require modification in respect of management skills.
In the achievement of health policy goals, particular management skills and competencies are desirable as well as an orientation that requires that public health and general management progressively overlap and move closer together. They already share a common policy and management agenda, including the following elements:
a focus on health and not just health care
a focus on outcomes and improvements in health status
achieving a balance between collective and individual actions.
Given the description in this chapter of health-care systems as political systems where a plurality of interests hold power, there are implications for public health and management. Public health cannot achieve change unless it is prepared to embrace management. Scientific detachment and political innocence alone will achieve little. At the same time, a set of core values and principles is vital if managers are to gain confidence to manage. The paradigm shift, therefore, posits that management and public health are inseparable in the creation and implementation of a change agenda in health care and that this should be reflected in the management education and development that those involved in public health receive.
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