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Modernising health care

Modernising health care: Reinventing professions, the state and the public

Ellen Kuhlmann
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    Modernising health care
    Book Description:

    Modernising health care: Reinventing professions, the state and the public is a crucial contribution to debates about the rapid modernisation of health care systems and the dynamics of changing modes of governance and citizenship. Structured around the role of the professions as mediators between state and citizens, and set against a background of tighter resources and growing demands for citizenship rights, Ellen Kuhlmann's book offers a much-needed comparative analysis, using the German health care system as a case study. The German system, with its strongly self-regulatory medical profession, exemplifies both the capacity of professionalism to re-make itself, and the role of the state in response, highlighting the benefits and dangers of medical self-regulation, while demonstrating the potential for change beyond marketisation and managerialism. Kuhlmann critically reviews dominant models of provider control and user participation, and empirically investigates different sets of dynamics in health care, including tensions between global reform models and nation-specific conditions; interprofessional dynamics and changing gender arrangements; the role of the service-user as a new stakeholder in health care; and the rise of a new professionalism shaped by social inclusion. Modernising health care provides new approaches and a wealth of new empirical data for academics and students of health policy, medical sociology and sociology of professions, and for health policy makers and managers.

    eISBN: 978-1-84742-165-4
    Subjects: Health Sciences

Table of Contents

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  1. List of tables and figures
    (pp. iv-iv)
  2. Introduction
    (pp. 1-14)

    Health care is a key arena of the modernisation of welfare states. Tighter resources and a changing spectrum of diseases, coupled with new modes of citizenship and demands for public safety, challenge the health care systems throughout the Western world. This book sets out to examine new perspectives on the governance of health care and to highlight the role of the professions as mediators between the state and its citizens. It brings the interdependence and tensions between the health professions, the state and public interest into focus that release ongoing dynamics into the health system. The emerging patterns of a...

  3. ONE Towards ‘citizen professionals’: contextualising professions and the state
    (pp. 15-34)

    This chapter stakes out the field for a sociological analysis of changes in health care systems as part of modernisation processes. The concept of citizenship provides the framework to link the issues of regulation and welfare state policy to the study of professions and professionalism. Linking citizenship and professions brings the state back into the study of professions, and in turn, professions into social policy and health care research. This new perspective on the governance of health care moves beyond the controversies between market, state and professional self–regulation. It highlights the role of the professions as mediators between the...

  4. Part I: Mapping change In comparative perspective

    • TWO Global models of restructuring health care: challenges of integration and coordination
      (pp. 37-56)

      Marketisation is the preferred modernisation strategy and an engine driving many changes in health care. It is introduced into very different systems, flanked by concepts of new public management (NPM) and decentralisation. The role of the service user is thereby becoming ever more important. The second line of development is based on the Alma Ata Declaration of the World Health Organization (WHO, 1981), which calls for the establishment of primary care as the solution to health care problems. The introduction of new models of primary care counts as central to the success of reforms. Marketisation and a radical shift away...

    • THREE Remodelling a corporatist health system: change and conservative forces
      (pp. 57-80)

      International calls for the coordination and integration of provider services, and participation of consumers, are echoed in Germany. In particular, the 2004 Health Modernisation Act paved the way for organisational change and new forms of managerialism and provider control. This chapter outlines the conditions and dynamics of modernising health care in a conservative corporatist welfare system, with particular emphasis on interoccupational change. By combining structure and policy, and static and dynamic analysis, it brings the reflexive nature of change in health into focus. Starting with an overview of the characteristics of the German health system, the major regulatory incentives of...

    • FOUR Drivers and enablers of change: exploring dynamics in Germany
      (pp. 81-96)

      An assessment of international developments in health care highlights significant change on the levels of regulation, organisation and professions that can foster social inclusion. Major elements of global models of modernising health care are taken up in Germany but transformed in a country-specific way. Characteristic of the German model of governance is the centrality of physicians’ associations and SHI funds. This polarised model of stakeholder regulation favours the medical profession and nurtures professional strategies of exclusion and hierarchy. The comparative perspective highlights that the most powerful drivers for change, namely a primary care approach and restructuring the organisation of care,...

  5. Part II: Dynamics of new governance In the German health system

    • FIVE Hybrid regulation: the rise of networks and managerialism
      (pp. 99-122)

      Changes in the regulation and organisation of work in the German health care system, particularly ambulatory care, are mainly governed by the medical profession. This chapter therefore focuses on officebased physicians and explores how global concepts of managerialism and provider networks play out in Germany. I will assess the developments on the levels of regulation – with respect to professional self–regulation, marketisation and managerialism – and the organisation of work. Analysis of physicians working in networks and gender analysis provide additional information on the enablers of change. Results show that there is no unique voice on regulation but that physicians are...

    • SIX Transformations of professionalism: permeable boundaries in a contested terrain
      (pp. 123-154)

      Professionalism is increasingly applied to the entire field of health occupations and falling into a more flexible and contextualised regulatory order pattern, which different actors can make use of in various ways. This chapter will explore the varieties of and opportunities for a more inclusive professionalism. I will assess changes in three occupational groups that act from very different positions in the health care system and set the dynamics against new demands on health care and citizenship. The findings highlight the flexibility and power of professionalism to transform itself. Physicians develop new strategies that link professionalisation to elements of new...

    • SEVEN New actors enter the stage: the silent voices of consumers in the landscape of biomedicine
      (pp. 155-178)

      When ‘citizen consumers’ fall ill, we can test the promises of new governance and citizenship. We can study the tensions between the new demands arising from the inclusion of users – as citizens, consumers and patients – in decision making and the interest–based strategies of the professions, especially medicine. This chapter brings in the patients’ perspectives. Do patients take on the role of expert patient? Does the model actually serve their demands and needs? Does it provoke shifts in the system of care? And how does the medical profession react to claims for user participation? Changes are analysed on meso and...

  6. Part III: The rise of a new professionalism in late modernity

    • EIGHT Professions and trust: new technologies of building trust in medical services
      (pp. 181-198)

      Professions play a key role in building trust in the provision of health care. At the same time, the capacity of professional self–regulation to serve the interests of the public and to ensure the quality and safety of health care has come under scrutiny. This chapter highlights new perspectives in the debate on trust in health care. Instead of simply echoing the ideological complaints of the medical profession on the potentially adverse effects of the tighter control of providers, it brings into view new ‘technologies’ of building trust. This approach directs attention towards the intersections and tensions between changing...

    • NINE The knowledge–power knot in professionalism: transforming the ‘currency of competition’
      (pp. 199-218)

      Knowledge is the key to professional power and the ‘currency of competition’ in the service sector. New models of governance that attempt to standardise knowledge and include user perspectives thus touch the core of professional power. This chapter contextualises the making of legitimate knowledge and outlines the conditions and options for a loosening of the knowledge–power knot of professionalism. I introduce a dynamic approach that moves beyond state control and market regulation, and links the approaches on knowledge and professionalism as a resource for occupational control with the social construction of knowledge. The findings of the study highlight that...

  7. TEN Conclusion
    (pp. 219-232)

    This book set out to assess the dynamics of the modernisation processes in health care. The study highlighted the interconnectedness and tensions between the professions, the state and the public, which release ongoing dynamics and new uncertainty into the policy process and practice of health care. We cannot understand change in health care without looking at professions as mediators between the state and its citizens, and empirically studying their options and strategies to shape the reform processes under way in all health systems. At the same time, the regulatory framework of the state and the role of service users are...

  8. APPENDIX: Research design of the empirical in-depth study
    (pp. 259-262)