Mellem styring og selvstyring: En undersøgelse af styringskompleksiteten i det kommunale sundhedsvæsen efter strukturreformen

Lone Thomsen & Helle Wagner Gehlert

Student thesis: Master executive thesis


Taking off from a profound curiosity of the management complexity of the Danish public sector and the way public sector leaders handle this complexity, we chose local community healthcare as the empirical field we would look into. In connection with the structural reform of the whole public sector of Denmark, also structures, objects and means of the health care sector were changed. The development towards further specializing of the hospitals and, at the same time, building new competencies in local community health care was strengthened. Especially rehabilitation and preventive care were given to local health care as new assignments. After identifying the two management paradigms New Public Management (NPM) and New Public Governance (NPG) as our main analytical framing of the thesis, our main question was articulated: What new complexity relating to different management paradigms has occurred in local community healthcare after the Danish structural reform, and how is this complexity dealt with from a leadership point of view? To be able to answer this question, we put forward the following four sub questions, touching on several analytical strategic moves and choices: 1. Which management forms seem to be prominent today in local community healthcare, and what tensions in management do they create? The purpose being to make the management complexity more concrete by pointing to existing management challenges here and now. On this issue, we used Osborne’s schematic presentation of elements relating to the three paradigms Public Administration (PA), New Public Management (NPM) and New Public Governance (NPG) to identify signs of the paradigms in specific management forms relating to local community healthcare 2. How do the new economic incentive structures work, after the structural reform has given part of the financial responsibility for the hospitals to local community health authorities? The purpose being to illustrate the management complexity that follows with the introduction of economic incentive structures, characteristic of the NPM-paradigm. On this issue, we used the Principal-Agent perspective and, in particular, we used ‘moral hazard’ as an important concept for analyzing the way these specific incentives were built and to what effect 3. How do preventive care and rehabilitation imply the citizen’s self-responsibility and self-management? The purpose being to illustrate the management complexity that follows the increasing demands for management of the citizen’s self-conditions and with that the citizen’s active participation in the welfare production, a problem relating primarily to the NPG management paradigm. On this issue, we used Foucault’s notion of power technologies and self technologies for analyzing the way in which new technologies set both citizens and employees in new ways, also including discursive displacements and changing professional identities in the analysis 4. How is this management complexity dealt with in practice? The purpose partly being to illustrate relevant management strategies for dealing with the cross pressure and partly being to understand the differences existing among local healthcare authorities. On this issue, we used Luhmann’s concept of couplings to analyze how leaders put together different rationales, agents and decision contexts in the effort of creating overall and coherent healthcare solutions Despite of limited empirical material, consisting mainly of written official documents and five fully transcribed interviews with top leaders of the local community healthcare authorities, our analysis pointed to the following central findings:  We did see traces of different and sometimes conflicting management paradigms, even within the same management forms, resulting in tensions in the management reality experienced by leaders. This analytical result confirms that the management paradigms do not supersede one another but, in contrast, co-exist in what has been termed archeological layers  With the P-A perspective, we showed how the incentive structure built to give local healthcare authorities financial responsibility for the hospitals, presented some serious problems and challenges: Preventing hospitalization of citizens is not always possible or even desired and general practitioners as independent agents are not part of the incentive structure. And even when prevention is possible, the effort might be too big compared to the possible gain. On another level though, the main challenge of the NPM-management form turned out to be a lack of support of entirety and coherence  Turning against rehabilitation as an empirical prominent NPG-management form, the analysis demonstrated how rehabilitation controls citizens and employees at the same time by demanding new mentalities and creating new relations, using among other things conversational technologies. Finally, the chapter picked up on the three management paradigms from the first analysis and pointed to the challenge of setting free citizens and employees (as part of the competition and free selection of the NPM-paradigm) and, at the same time, controlling that freedom in a specific direction of employees activating citizens and citizens undertaking an active citizenship (as part of the NPG-management form)  Stepping on the challenge of the division between management and self-management and looking into leaders’ strategic way of handling these specific conditions in practice, we found that efforts to couple agents, decision contexts and rationalities from different paradigms are indeed made, but in different ways in the two case-municipalities, linking one primarily with a management way of thinking and the other in the midst between a management and governance way of thinking. Either way, we still saw signs of lack of entirety and coherence Summing up, the thesis has shown how new dynamics between the different paradigms of PA, NPM and NPG should be invented in order to embrace the numerous demands on public healthcare in Denmark, thereby creating a future that meets citizen’s public security, society’s optimal use of its resources and a whole and coherent performance all in all.

EducationsMaster of Public Administration, (Executive Master Programme) Final Thesis
Publication date2011
Number of pages98