Does Professionalism Matter? in Health and Education It Still May

Listener April 20, 2002.

Keywords Education; Governance; Health; Labour Studies

In Graham Scott’s Business Roundtable published Public Sector Management in New Zealand”, the ex-Secretary of the Treasury provides an account of the late 1980s public management reforms with which he was closely involved. The book includes a few pages on critics of the reforms, including a half-hearted account of my views in The Whimpering of the State (and these columns). Scott writes, ‘Easton makes the extraordinary claim that reformers ignored, or sought to undermine, the personal responsibility and professionalism of the core public sector.’ I am not sure I went that far, but I did report American expert Alan Schick’s concern that there appeared to be an unaddressed tension between the reform’s managerialism with its emphasis on accountability, and professionalism which emphasises responsibility. Curiously (I will not write ‘extraordinarily’), Scott’s book does not provide much evidence that professionalism is a central concern, for its few mentions are desultory. There is more concern about ‘professional capture’, the danger that professionals will administer the system in their interests rather than the wider public good. (The issue echoes the corporate management/shareholder tension I wrote about in my last column Guard Dogs That Fail to Bark.)

In management theory there is a dichotomy between the ‘scientific management’ and ‘human relations’ approaches. Scientific management emphasises a pyramid of control topped by a single chief executive, with a need to provide mechanisms to ensure that those at lower levels do what is required. The human relations approach was a reaction, arguing that effective work processes require a more decentralised management style, in which social norms and non-economic rewards are crucial, and collegial relations important. The public sector reforms were dominated by scientific management notions. Universities, once preeminently collegial, are now by law required to be hierarchal, with the vice chancellor the chief executive rather than the ‘primus intra pares’ academic.

We are so seduced by the notion of ‘scientific management’ that we become insensitive to it. That those who deal with employment relations are likely to be in a ‘human resources’ divisions, suggests the workers are to be treated just like any other input in the firm, not as human beings. Or consider the State Services Commission report, Review of the Centre’, released in January, on how the core public service should be managed. It uses the ‘accountability’ notion 36 times, but ‘responsibility’ gets only 14 mentions, and ‘professional’ a mere four.

The core public service may be moving away from notions of professionalism and individual responsibility. But the public still requires them in the education and health. A doctor recently complained to me that a manager had closed beds in his ward without any discussion with the staff involved. He was not questioning whether the beds should have been eliminated – how could he know all the issues if he was not informed. His concern was the lack of consultation, for under scientific management those lower in the hierarchy need not be involved, even though the upper level managers do not have the professional competence to evaluate the effect of a decision on patients. Their competence is its impact on costs. Another doctor has complained publicly that entire wards have been closed down, without any appreciation of the implications for cross-infection in the closely packed remaining ones. He says that patients have died as a result. Not however, I imagine, to any consternation to those who made the decision, since they are only accountable. It is the professional and responsible doctors and nurses who grieve over unnecessary deaths. Their concern was sufficient to force an enquiry about emergency services at the Christchurch Hospital, which proved very critical of the managers’ competence.

One may ask just how competent the new managerial hierarchies are. They may be good at creating corporate plans and mission statements – do they have any real effect? – but while the impending shortage of radiation therapists to treat patients was known in 1998, it took last years’ crisis for any action to be taken. What does that say of the strategic capacity of health sector managers?

The universities are in suppressed turmoil too. Academics complain that once their administrations were to service the teaching and research, whereas nowadays the academics’ main function seems to be to earn sufficient fees to fund the administration. When universities need to reorganise, it is usually done without consulting their staff, who are bewildered rather than informed. The same happens to clinicians, who find a big chunk of their medical budget unilaterally charged to overheads. In a hierarchical system there is no accountability to those at the sharp end below.

The tension between the managers and professionals in our hospitals is most evident in Christchurch, but exists less publicly elsewhere. The new District Health Boards, with their elected representatives, may become the arbiters between the antagonists. They remain accountable fiscally to the central government, but they are likely to insist that managers recognise and respect the professionalism of the doctors and nurses and involve them in the resource decisions. The most important effect of the current health reforms may be a better balance between scientific management and human relations.

Note The arguement in greater detail appears in DOES PROFESSIONALISM MATTER? (NZIPA Paper)