The complexities of negotiating governance change: introducing managerialism in Italy

Abstract

Since the beginning of the 1990s, health policy in Italy has been characterised by continuous reform as reflected by the frequency of new measures. Importantly, the reforms have changed considerably many aspects of the health-care system, including the governance of medical performance. The new measures fall into two types: regionalisation and transformation of local providers into 'health-care enterprises'. In relation to the governance of medical performance, more specifically, the reforms have entailed the introduction of budgeting and quality assurance, the creation of new managerial roles, and the transformation of existing roles, as well as the introduction of new mechanisms for evaluating medical performance. In terms of the specific forms of governance, the reforms have reinforced hierarchy-based forms of governing intermeshed with party governance, and have re-defined professional self-regulation by strengthening collective forms of professional self-regulation. The design and implementation of the reforms are subject to a complex process of negotiation, which involves a wide range of actors spread across different levels of governance and takes place in relation to all aspects of the governance of medical performance.

Professionalization without Autonomy: The Italian Case of Building the Nursing Profession

“…Medical dominance has undergone a process of decline since the early 1990s due to some changes in health systems, including health system reforms, consumerism, the professionalization of non-medical health occupations, as well as the hyper-specialization and division of the medical profession into different roles, which have weakened and fragmented its power to control health and pharmaceutical services (Andri & Kyriakidou, 2014;Bury & Taylor, 2008;Coburn, 1999Coburn, , 2006Gordon, 2005;Parse, 1998;Tousijn, 2002Tousijn, , 2006Tousijn & Giorgino, 2009). Despite these changes, however, in the Italian context, the medical profession still plays a dominant role in all jurisdictions in the system of health professions, having a particular influence through the four types of dominance described by Tousijn.…”

The Translation of Hospital Management Models in European Health Systems: A Framework for Comparison

“…While in England and Denmark the focus has been on developing clinical directorates based on a single line of management accountability, this has been less obvious in France and Italy. In the latter, the decision was made to establish executive committees within each department (or directorate) made up of the chiefs of clinical units with powers to nominate the chair and veto key decisions (Tousijn and Giorgino, ).…”

“…Competition was immediately discouraged through the arrangement of funding caps for individual hospitals. Under the close scrutiny of local politicians CEOs were required to focus on improving weak areas of their hospitals, rather than incentivizing their competitive advantages (Tousijn and Giorgino, ). Indeed, at one point in 2003 the Minister of Health, himself a doctor coming from the largest teaching hospital in Milan, explicitly linked quality problems in the Italian NHS to the introduction of too many managers (Anonymous, ).…”

Integrating health and social care: Interprofessional relations of multidisciplinary teams in Italy

“…This process entailed a radical change of the organizational structure of hospitals and other health organizations, including the creation of entirely new managerial roles, such as the general manager, and the transformation of once purely medical roles, such as department heads, into hybrid roles (medical-managerial). General managers were, and still are, in part executives recruited outside the medical profession; so for the first time healthcare organizations were run by non-medical managers (Tousijn and Giorgino, 2009). As in other countries, Italian doctors viewed the whole process as a serious threat to their professional autonomy, as established by a national survey conducted in 2004: about two-thirds of the surveyed doctors declared that their autonomy was being challenged and that managerial control of healthcare had reduced the quality of care (Speranza et al, 2008;Tousijn, 2006).…”