Enterprise discourse, professional identity and the organizational control of hospital clinicians

Abstract

Recent reform of the healthcare sector in New Zealand involved the corporatization of public hospitals, and the contractualization of social relations between and within institutions. Various attempts were made to incorporate hospital clinicians within some system of organizational control in order to make them accountable for the resources consumed as a consequence of their treatment decisions. This paper considers how the general intention of government to control, curtail or influence the professional autonomy of hospital clinicians was played out in the context of a single New Zealand hospital. It considers the possibility that power effects of discourses associated with such neo-liberal programmes of reform could influence the subjectivity of hospital clinicians, aligning their clinical behaviour with the broader goals of the governmental programme. It explores how individuals manoeuvre in relation to these discourses of management and enterprise, whether in acceptance, resistance or compromise. The resu lting outcomes are complex and varied, as individuals negotiate dominant discourses in the construction of identity and self.

Descriptors: discourse, governmentality, identity, healthcare, professions

Introduction

In recent decades, the New Zealand government, like those of many other developed countries, has been struggling with the problem of reconciling increasing public expectations over healthcare with limited economic growth. An ageing population with an increased life expectancy, together with advances in medical technology and practice, have increased opportunities for diagnosis and treatment. In view of ever-increasing expenditure on healthcare, New Zealand governments have perceived a need to limit or ration resources available for healthcare provision. Influenced by an international move towards a neo-liberal agenda in dealing with the public sector, the New Zealand government instituted a reform of its healthcare services as one of a number of initiatives to redefine the role of government and create a more business-like and efficient public sector.

Hospitals are a major source of healthcare expenditure, and much of the resource allocation in these settings is driven by hospital clinicians exercising their autonomy over patient treatment decisions. In this sense, the reform of public healthcare provision in New Zealand can be constructed as a conflict between central government and the medical profession over the financial implications of medical autonomy (cf. Dent 1993). This paper considers how the intention of central government to control, curtail or influence the professional autonomy of hospital clinicians was played out in the context of a New Zealand public hospital. It considers the possibility that power effects of enterprise discourses associated with a neo-liberal programme of public-sector reform could constitute hospital clinicians as enterprising subjects, aligning their clinical behaviour with the broader goals of the governmental programme.

This study is informed by a body of work, written in a Foucauldian tradition, on issues of discourse, subjectivity and governmentality in organisations (e.g. Knights and Morgan 1991; Rose 1992; Johnson 1995; du Gay et al. 1996). This literature has played an influential role in the increasing emphasis placed on discursive approaches to organizational analysis (Fairclough 1995; Chia 2000). However, as Dean (1999) cautions, the authors contributing to this literature 'stand in different relations to Foucault's own work' (p. 10), and should not be seen as representing a purely Foucauldian position.

Foucauldian studies of organization have been criticised for downplaying the significance of human agency and failing to address the way people 'agentially play with discursive practices' (Newton 1998: 430) in their constitution as subjects of power/knowledge relations (Newton 1998; Halford and Leonard 1999; Reed 2000). Following Newton (1998), this study attempts to show how discursive practices are played out in the local context of a hospital, a complex organization with strong internal cultures and a negotiated order between diverse occupational and professional groups (Reed and Anthony 1993). It explores how individuals manoeuvre in relation to discourses of management and enterprise, whether in acceptance, resistance or subversion.

The study can also be usefully located within a literature that considers the changing nature of professional roles under the new managerialism in the public sector (e.g. Dent 1993; Causer and Exworthy 1999; Kitchener 2000). Changing institutional contexts in the public sector, including the introduction of market forces and new information technologies, are tending to break down established professional jurisdictions into more contingent relationships of knowledge, work and status. In the health arena, we are witnessing the greater interpenetration of managerial and medical practices and knowledges, with a consequent blurring or re-negotiation of the professional boundaries between management and medicine (Bloomfield and Coombs 1992; Ashburner and Fitzgerald 1996; Cohen and Musson 2000).