Governance and Strategy
Lecture 1: Governance – principles and challenges ahead
There might be things happening in the
outer context that might influence what is
happening in the healthcare organisation
(inner context). These things can be
developments in social expectations,
culture, technology, politics. E.g.
international agreements, budget cuts,
staff shortage, technological innovation.
The inner context might also try to
influence/impact what is happening in the
outer context. The interaction between
these contexts is interesting.
Past and current challenges for healthcare managers that have implications for healthcare
organisations:
- Brexit
The UK leaving the EU with no deal has possible implications for healthcare organisations.
One of them is the availability of medicine. It is unclear whether medicine produced in the
UK would still be available in the EU. There was a specific list of medicine where there was no
solution for yet. However, healthcare organisations have some possibilities. Some
organisations decided to make the medications themselves. Another option is to look
elsewhere in the EU for the availability of those medications. This list was interesting because
it was kept a secret. People, healthcare organisations and the government were afraid that
patients would stack up these medications.
Another implication is the CE mark approval for medical devices. The CE mark means that
something is approved for the whole EU to use. Some medical devices were approved in the
UK. There was unclarity about if the CE marks approvals from the UK would still be valid
when the UK would leave the EU with a no deal. Initially the minister said that this was a
problem for healthcare organisations, to find out which medical devices have a CE mark
approval from the UK and find ways to surpass that or find medical devices elsewhere.
Healthcare organisations would have a hard job trying to find out from every medical device
if it has been approved and what the medical implications are, because they use so many.
The academic medical centres wrote a letter saying they need emergency legislation to deal
with this problem because healthcare organisations cannot deal with this alone. That led to
the instalment of the emergency legislation and eventually the healthcare organisations
influenced the policy on this matter.
- Staff shortages
Policy solutions on a state-level (macro): e.g. role of task substitution (e.g. nurses taking over
tasks of doctors), introducing technology as a solution (maybe technology can take over the
work of people), role of volunteers and informal care givers (family taken care of patients
instead of only the caregivers).
What happens within organisations (meso)? E.g. who bears clinical responsibility (in task
substitution; the doctor or the nurse?), complexities with implementing and using technology
(technologies don’t always work great in practice), professional boundaries (between
volunteers and professionals).
, How do people act (micro)? E.g. new professional roles often rely on trust (task substitution),
what do patients want, technologies embedded in existing routines (‘I am Alice’). It is
important to study how these technologies work out in practice on a personal level.
- COVID-19/Corona virus
On a policy level: from government to governance reliance on and influence of different
stakeholders:
o Role of mayor in the safety regions
The Netherlands is divided in several safety regions that coordinate crisis and
disaster management
Mayors supervise these safety regions
Responsibility is being shifted from the central government position to a
more local level
o RIVM as centre of expertise
It also shows power differences. E.g. medical specialist association that ‘governs’ via the
media. First, schools remained open. When they mentioned that schools should also close,
the government did not really have a choice anymore. Decision-making was influenced by
the media.
What happens in organisations? Organisational networks and layers:
o Sharing protective gear in and between organizations (but also a push towards
government to order more gear and instruments)
o Coordinating intensive care patients (now national coordination)
Intensive care patients were coordinated amongst hospitals
o Self-producing IC ventilators
Because of shortages
Preparing for the storm
o Empty hospitals, limiting ‘normal care’
Outside North-Brabant, hospitals are preparing for an increased number of
intensive care patients
Scheduled care is being put on hold, which causes problems for e.g. people
waiting on donor organs
How do people act?
o Ensure (cleaning) staff keeps coming to the hospital
The staff needs to be protected enough because they have a high risk
o Choices doctors and nurse have to make (Italian nurse’s plea)
Who will be treated and who will not be treated?
o Non-Corona patients that might need care but now postponed, what physical and
mental consequences does this have on them?
o Behavior of society, e.g. going to the beach and parks
What about aged care, disability and youth care? We increasingly hear about this in the
media, but it remained rather quiet for the first weeks. E.g. loneliness, required help and
assistance.
What about the patient perspective? It has not really been taken into account until recently.
,Framework
Healthcare systems (macro):
- Health policies
- Role of patients and citizens
- View on care and health
- Role of professional and patient associations
Healthcare organisations (meso):
Health policies travel downwards and shape the everyday reality of care organisation.
- Role of managers, professionals, patients, municipalities, social care etc. (stakeholders)
Day-to-day interactions of individuals (micro):
- Between professionals and patients/care takers
- Between professionals and managers
This framework is a tool to study what is happening in healthcare. In reality, however, it might not
always be so easy to distinguish between macro- and meso-level. These three divisions helps us to
see how policy works out in practice. The macro-level will influence what is happening on a meso-
and micro-level but also the other way around. E.g. staff shortage.
Governance and strategy is about analysing how policy on a macro-level impacts what is done in
organisations on a meso-level and how people act and interact on a micro-level and vice versa.
Governance
Governance serves as an umbrella concept, including different forms and sets of managerial and
professional modes of governing, institutions and actors. Governance means different things on a
macro-, meso- and micro-level. Central in all definitions is that it has got some element of steering.
Development from government to governance Government generally resembles places of power,
where decisions are made. This has some underlying assumptions. One of them is that power of the
government is mostly centralised and directed in a top-down fashion. It assumes that powerful
government representatives determine the course and outcome of decision making. It assumes that
important political decisions are made in e.g. The Hague and then implemented elsewhere in the
country (top-down). The development from government to governance is something that Rhodes
(2007) describes as “hollowing out the state”. There is more and more responsibilities going from a
government (central position, the state) to elsewhere (e.g. market, municipalities, European Union,
community, public/private providers). The assumptions of the state as a central power has shifted. It
might still have the end responsibility in many cases but a lot of responsibilities have been shifted to
other stakeholders in the society. This means that their level of control has decreased as well.
Strategy
Strategy implies heading in to a certain direction, aiming for a certain goal. There are different
perspectives and conceptualisations of strategy, in theory but also in practice. Most examples of
strategy come from the private sector, e.g. Kodak. As an analogical photography company, they
neglected the digital photography. This led to other companies being way more successful and Kodak
going broke. Eventually the company still remained but they do not make cameras anymore. Missing
the boat had a big implementation on the future and existence of that company. This is not
unfamiliar in healthcare, e.g. hospitals going out of business. Strategy is meant to keep a business
afloat. Healthcare organisations need to adapt to the outer context. Technological developments
have been a big part of the strategy of hospitals (e.g. artificial intelligence).
, Lecture 2: Decentralization of care – the citizen perspective
Theory
Hybrid governance in Dutch healthcare
There is a mixture of market principles, government
steering, community participation and all kinds of
regulations within the medical profession. In sum, the
government system consists of 4 different domains: market,
government, community and the medical profession. This is
being translated into the way we govern the healthcare
system.
Fundamental characteristics:
- Private delivery
There is a tradition of private delivery of healthcare. This means that most of our healthcare
institutions, like hospitals, are privately owned and not in the ownership of the government.
They are foundations, cooperation’s or market parties. However, they are delivering a public
good: healthcare. This is the mixture/hybridity within a healthcare institution.
- Professional autonomy
Within hospitals/healthcare organisations, there is a lot of professional autonomy. This
means that the healthcare professionals (e.g. doctors, nurses) are hugely autonomous in the
way they should practice their profession. Of course they are also regulated by laws and
organisational rules. In the end, they have to take professional decisions formed by their
profession and the way they are educated. Also, they have experience in their profession.
- Public means held by private organisations
The public means, the way we finance our healthcare, is also owned by private organisations
(health insurers). The biggest part of the money, which is being used in healthcare, is in
private hands. It is not tax money but it is premium money, which is being put in by every
citizen, employee and employer in the Netherlands. That is the way the healthcare system is
being financed. This also shows the hybridity. Public goods, private finances, private delivery,
professional autonomy but in the end, huge responsibilities for the government.
- Huge government responsibilities, limited government power
We look at the government to act and protect (e.g. corona crisis). This is also regulated in our
constitution. The government has limited power to live up to this responsibility because the
government is depended on health insurers, healthcare professionals and healthcare
institutions.
Practical implications of the governance model:
- Inherent hybridity (commercial and guardian syndromes)
Most of the time it is a combination of a commercial/citizen/client perspective and a
guardian/protection/collective perspective. It is a mixture of individual responsibility and
choice with collective responsibility and solidarity.
- Variety of public-private partnerships and networks (national and local)
Due to this mixture, in organisational and institutional sense, we see a lot of variety in public-
private partnerships and networks (see figure above).
