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MODERNISING HEALTH
CARE
Reinventing professions, the state
and the public
Ellen Kuhlmann
First published in Great Britain in September 2006 by
The Policy Press
University of Bristol
Fourth Floor
Beacon House
Queen’s Road
Bristol BS8 1QU
UK
Tel +44 (0)117 331 4054
Fax +44 (0)117 331 4093
e-mail [email protected]
www.policypress.org.uk
© Ellen Kuhlmann 2006
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested.
ISBN-10 1 86134 858 4 hardcover
ISBN-13 978 1 86134 858 6 hardcover
Ellen Kuhlmann researches and teaches at the Centre for Social Policy
Research at the University of Bremen, Germany.
The right of Ellen Kuhlmann to be identified as author of this work has
been asserted by her in accordance with the 1988 Copyright, Designs and
Patents Act.
All rights reserved: no part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise without the prior
permission of The Policy Press.
The statements and opinions contained within this publication are solely
those of the author, and not of The University of Bristol or The Policy Press.
The University of Bristol and The Policy Press disclaim responsibility for any
injury to persons or property resulting from any material published in this
publication.
The Policy Press works to counter discrimination on grounds of gender, race,
disability, age and sexuality.
Cover design by Qube Design Associates, Bristol.
Printed and bound in Great Britain by MPG Books, Bodmin.
 Contents

List of tables and figures iv

Acknowledgements v
Abbreviations vi
Glossary vii

Introduction 1

one Towards ‘citizen professionals’: contextualising 15

professions and the state

Part I: Mapping change in comparative perspective

two Global models of restructuring health care: challenges 37
of integration and coordination
three Remodelling a corporatist health system: change 57
and conservative forces
four Drivers and enablers of change: exploring dynamics 81
in Germany

Part II: Dynamics of new governance in the German health

system
five Hybrid regulation: the rise of networks and managerialism 99
six Transformations of professionalism: permeable boundaries 123
in a contested terrain
seven New actors enter the stage: the silent voices of consumers 155
in the landscape of biomedicine

Part III: The rise of a new professionalism in late modernity

eight Professions and trust: new technologies of building trust 181
in medical services
nine The knowledge–power knot in professionalism: transforming 199
the ‘currency of competition’

ten Conclusion 219

References 233
Appendix: Research design of the empirical in-depth study 259
Index 263

iii
Modernising health care

List of tables and figures

Tables
3.1 Health reform Acts from the 1990s onwards: major changes 62
and policy goals
4.1 Enablers of change and areas of expected dynamics 96
10.1 Diversity of professionalism between exclusion and 221
social inclusion
A.1 Research groups, settings and methods 260

Figures
i.1 Research design: reinventing professions, the state and 8
the public
4.1 Drivers for modernisation and application to Germany 95
10.1 Professions, the state and the public as a dynamic triangle 225

iv
 Acknowledgements

I would like to express my thanks to those who have contributed in

different ways to this work. A grant from the University of Bremen
(ZF/27/820/1) allowed me to do the research and work on the book.
The Statutory Health Insurance (SHI) Physicians’ Associations North
Rhine and Westphalia-Lippe and the Physicians’ Chamber North
Rhine supported a questionnaire study of office-based physicians.
Other professional associations helped me to gather primary material
and organise focus group discussions and expert interviews, namely
the Physicians’ Chamber Bremen, and the Federal and Regional
Associations of Physiotherapists and Surgery Receptionists. Rolf Müller
carried out statistical analysis; Maren Stamer assisted with the
organisation of focus groups with patients from self-help groups and
collected additional expert interviews in 2005; and Nadine Helwig,
Oda von Rhaden and Brunhild Schröder contributed as students to
the project. Angela Rast-Margerison, with her usual patience and
proficiency, translated parts of the book and edited the full typescript;
she helped to maintain confidence that my writing will turn out as an
English typescript. I am also grateful to the numerous participants in
the study.
Numerous colleagues from the Research Network ‘Sociology of
Professions’ of the European Sociological Association, and the Research
Committee ‘Professional Groups’ of the International Sociological
Associations, as well as the audience of other international meetings
on the professions, health care and social policy, provided the
opportunity to discuss my research in its early stages and helped to
sharpen my theoretical arguments. My special thanks go to those who
commented on papers or draft chapters or otherwise collaborated
during the research process and encouraged me to bring the German
case of modernising health care into an international debate; in
particular, Judith Allsop, Birgit Blättel-Mink, Celia Davies, Julia Evetts,
Gerd Glaeske, Karin Gottschall, Michael Hülsmann, Petra Kolip and
Mike Saks. I owe a great deal to Viola Burau for bringing me closer to
social policy and comparative approaches and for her inspiring
comments on the draft typescript, and to Janet Newman, who
supported my ideas at a crucial point in the writing and invited me to
The Open University. And finally, many thanks to the team at The
Policy Press for their kindness and support during the publication
process.

v
Modernising health care

Abbreviations

CAM complementary and alternative medicine

CHD coronary heart disease
CNM certified nurse midwife
DMP disease management programme
EBM evidence-based medicine
EU European Union
GMC General Medical Council
GP general practitioner
HEDIS Health Plan Employer Data and Information Set
HMO health maintenance organisation
IoM Institute of Medicine
MCO managed care organisation
NGO non-governmental organisation
NHS National Health Service (Britain)
NP nurse practitioner
NPM new public management
PA physician’s assistant
PCG primary care group
PCT primary care trust
RCT randomised controlled trial
SHI Statutory Health Insurance
WHO World Health Organization

vi
 Glossary

Ambulatory care (Ambulante Versorgung)

Health care provided outside the hospitals by office-based generalists
and specialists in Germany
Disease management programmes (DMPs)
New models of ambulatory care in Germany that focus on certain
chronic illnesses: coronary heart disease (CHD), diabetes mellitus
and breast cancer
General (medical) care (Hausärztliche Versorgung)
In the German context the term refers to care provided by four
types of office-based generalists (Hausärzte): physicians specialised
in general medicine; physicians who provide general medical care
without specialisation (Praktische Ärzte); physicians specialised in
internal medicine who have to opt for either general care or specialist
care; paediatricians are also partly included
General practitioners (GPs)
Physicians who provide general medical care in countries with a
gatekeeper system
German gatekeeper model (Hausarztmodelle)
Pilot projects aimed at targeting ambulatory care in Germany
through a gatekeeper model of office-based generalists; participation
is voluntary and open to those who provide general care
Health occupations
In the German context the term refers to all health care workers
who are not members of the self-regulating professions (physicians,
dentists)
Health professions
Used in the German context the term refers to the classic professions,
particularly physicians; used in an international context it comprises
all qualified health care workers
Modernisation/late modernity
Used to host broader developments and transformations in various
areas of societies, that is, changing modes of citizenship, without
applying ‘grand narratives’ of ‘late’ or ‘post’-modernity or ‘never
have been modern’; with this respect, ‘late modernity’ refers to
features of 21st-century societies that are in some respect different
from earlier times

vii
Modernising health care

New governance
Refers to a complex set of regulatory mechanisms and more hybrid
patterns that go beyond hierarchical institutional regulation
(performance)
Office-based physicians
Physicians who provide ambulatory care in Germany, comprising
generalists and specialists
Primary care
Refers to multidisciplinary caring models in Anglo-American
countries according to the World Health Organization (WHO)
definition
Professional autonomy
Used as a normative term related to the claims of professions on
self-determination
Social Code Book V (Sozialgesetzbuch V)
Legal framework basically regulating statutory health insurance and
health care in Germany
Statutory Health Insurance (SHI) funds/sickness funds
(Gesetzliche Krankenkassen)
Non-profit health insurance funds with mandatory membership of
approximately 90% of the citizens; together with physicians’
associations they form the core of joint self-administration of SHI
health care in Germany
User/consumer/patient
‘User’ marks a position in relation to providers and avoids normative
distinctions;‘consumer’/‘consumerism’ refers to a political discourse
of users as stakeholders;‘patient’ refers to the micro-level of provider–
user relationship and a medical discourse of user participation

viii
 Introduction

Health care is a key arena of the modernisation of welfare states.Tighter

resources and a changing spectrum of diseases, coupled with new
modes of citizenship and demands for public safety, challenge the
health care systems throughout the Western world.This book sets out
to examine new perspectives on the governance of health care and to
highlight the role of the professions as mediators between the state
and its citizens. It brings the interdependence and tensions between
the health professions, the state and public interest into focus that
release ongoing dynamics into the health system.The emerging patterns
of a new professionalism in late modernity and interprofessional
dynamics lie at the centre of my investigation.
I have chosen the German health care system, and in particular
ambulatory care, as a case study to place this national restructuring in
the context of European health systems and global reform models. I
have applied a multidisciplinary approach that links the study of
professions to social policy and health care research. My empirical
research takes into account the provider and the user perspective, and
a gendered division of the health workforce. Investigating the dynamics
of new modes of governance in a non-Anglo-American context of
corporatist stakeholder regulation expands the scope of health policy
and makes new options apparent that move beyond marketisation and
managerialism. The book highlights the context-dependency of
medical power and the significance of regulatory frameworks in
targeting the rise of a more inclusive professionalism. It helps to clarify
whether and how new governance creates ‘citizen professionals’ that
better serve 21st-century societies’ health care needs and wants of a
diverse public.

Understanding the dynamics of new governance in

health care
Health care is being modernised around the Western world. New
models of governance have been introduced to reduce medical power
and to advance an integrated health workforce and the participation
of users.These developments are part of broader changes in the public
sector and society at large. They can be explained in terms of
modernisation processes that are related to changing modes of
citizenship and new models of governance.The restructuring of health

1
Modernising health care

care mirrors ‘new directions in social policy’ (Clarke, 2004) and a

move away from hierarchical institutional regulation towards more
flexible and hybrid patterns of governing ‘peoples and the public sphere’
(Newman, 2005a). At the same time, “health care politics are more
than a subset of welfare politics and the health care state is more than
a subsystem of the welfare state” (Moran, 1999, p 4). The ‘meeting’ of
changing welfare states and changes emanating from the health care
system and the health professions need further investigation; controversy
remains especially as to whether new governance actually shifts the
balance of power away from the medical profession, and which model
of provider organisation serves best to improve the accountability of
professionals.
In all countries cost containment is a strong policy driver, and
marketisation and managerialism are the uncontested ‘favourites’ of
policy makers. “Reform has become a way of life for health services,
not only in the UK, but throughout the western world” (Annandale
et al, 2004, p 1; see Blank and Burau, 2004; Dubois et al, 2006).
However, to date, neither the potential for nor obstacles to change
have been investigated in a non-Anglo-American context. Strategies
are developed against a backdrop of Anglo-American health systems
but new terms are travelling around the world as part of a global
discourse on reform. Globalisation and the European unification
reinforce the tensions between global models of regulation and provider
organisation, and local conditions, needs and demands on health care.
Germany fits the typology of neither market-driven nor state-centred
restructuring; it has its one strong and long-lasting tradition of social
policy, and the longest tradition of compulsory social health insurance
(Greß et al, 2004). While Bismarckian social policy, especially health
care, marked a model of social security and justice for about a century,
the corporatist structure is nowadays viewed as a barrier to innovation.
At the same time, elements of corporatism and professional self-
regulation allow for flexibility and responsiveness and may ‘buffer’
social conflict (Stacey, 1992); they are even gaining ground in state-
centred health systems (Allsop, 1999).Transformations of the corporatist
system of stakeholder regulation thus provide the opportunity to study
both weaknesses and benefits of medical self-regulation. Placing
developments in the German health system in a global context of
health care restructuring helps to better understand how regulatory
frameworks shape and reshape medical power, and brings into focus
new health policy options.
A further contribution of this study to the debate on governing
health care is its focus on the professions.This approach moves beyond

2
 Introduction

institutional regulation and brings into view reflexivity of change and

different sets of dynamics. I argue that professions are key players in
health care and mediators between states and citizens. Each side needs
the other, and intersections and tensions of interest are therefore
inevitably embedded in the triangle comprising health professions,
the state and the public. New patterns of governance and new demands
on health care challenge the health professions, but in various ways
that are not fully under control of governments. Professionalism has
the capacity to remake itself and ensure professional power under
conditions of changing welfare states and new demands on health
care services.
However, the varieties of welfare states enhance the varieties of citizen
professionals that contribute in different ways to contemporary demands
on social inclusion and citizenship, and the making of an integrated
health workforce (Saks and Kuhlmann, 2006: forthcoming). In
particular, the question must be addressed as to whether a strong
stakeholder position of the medical profession in Germany and lack
of a comprehensive coordination of services provided by other health
occupations actually allows for the broadening of the range of providers
of care and the epistemological basis of that care. Does this form of
regulation produce patterns of “uncertain and evolving dynamic”
(Tovey and Adams, 2001, p 695), similar to those described in
multidisciplinary models of primary care in the Anglo-American
systems? Does it produce a workforce revolution in health care (Davies,
2003)? And what, then, are the ‘drivers’ for change and the ‘enablers’
of modernisation in the German system?
An approach on professions as mediators in health care systems
provides the opportunity to assess dynamics across different professional
groups and macro, meso and micro-levels of change, and to link
structure to culture and action dimensions of change. This approach
moves beyond the typologies of welfare states and health care systems,
and the controversies of marketisation/bureaucratic regulation, and
submergence/convergence of health systems. It directs attention
towards actors and agency, and the interplay of institutional regulation,
cultural norms and formal and informal procedures. Linking change
in the professions to changing patterns of governance stimulates a
debate on ‘professions and the state’ (Johnson et al, 1995) and ‘professions
and the public interest’ (Saks, 1995) in a context of changing health
policies and user demands. It may also contribute to new approaches
in social policy that call for “rethinking governance as social and
cultural, as well as institutional practices” (Newman, 2005b, p 197).

3
Modernising health care

Remaking governance, transforming professionalism

New health policies and transformations in society enhance the “fall
of an autonomous professional” (Kuhlmann, 2004, p 69) and create a
new type of ‘citizen professional’ and ‘citizen consumer’.The emerging
new tensions and dynamics caused by the diversity of interests and
demands between and within the various groups of providers and
stakeholders give rise to a new professionalism in 21st-century societies.
This new pattern is markedly different from that of industrialised
societies in the late 19th and 20th centuries and the ‘golden age’ of
professions in the postwar period. This perspective brings into view
both the transformability of professionalism and the role of the state
in targeting and shaping transformations of professionalism.
Modernisation processes in health care touch on a classical issue in
sociology, namely the role of the state and bureaucracy, a role that has
been the subject of controversy since the work of Marx and Weber.
These controversies recur in the study of professions; concepts of the
state have been critically reviewed and complemented from different
theoretical perspectives (Johnson, 1972; Larson, 1977; Coburn, 1993;
Johnson et al, 1995; Macdonald, 1995; Saks, 2003a; Evetts, 2006a).
Freidson (2001), among others, claims, for instance, that professionalism
stands as a ‘third logic’ next to market and bureaucracy. However, state
regulation itself is undergoing change, and the Weberian definition of
the state as an institution that claims a monopoly of legitimate authority
and power needs to be reassessed. For example, ‘open coordination’
makes up a core strategy of the European Union to improve the
participation of its various member states (Commission of the European
Countries, 2004). New forms of open coordination and network
structures are signs of an ongoing development towards the “re-shaping
of the state from above, from within, from below” (Reich, 2002,
p 1669).
The sociology of the professions offers a framework to further outline
these processes of ‘reshaping’ the state and to assess the enhanced
dynamics in health care. By focusing on the professions and
professionalism, traditional lines of sociology are taken up and set in a
new context.The work of Durkheim (1992 [1950]) and Parsons (1949),
for example, highlights the prominent role of the professions in social
developments from different theoretical perspectives. From a historical
point of view the rise of professionalism and the emergence of
professional projects are characteristic of civic societies (Bertilsson,
1990; Burrage and Thorstendahl, 1990; Larson, 1977). Perkin (1989)

4
 Introduction

goes even further and describes the relation between professions and
society as the ‘rise of professional society’.
Professions continue to play a pivotal role in the concepts of welfare
states and the transformation to service-driven societies, which are
characterised, on the whole, by an expansion of expert knowledge
and professionalism. Moran argues that “the welfare state was a
professional state; it depended on professionals both for the expertise
needed to formulate policy and to deliver that policy” (2004, p 31).
This statement underscores the interdependence of professions, the
state and the public, and the need to balance different interests. Against
the backdrop of an increasing need to define criteria for the distribution
of scarce resources, and to legitimise these decisions in the light of
social equality and citizenship rights, professions and professionalism
are needed, perhaps more than ever.
Following these argumentations, professions are the ‘cornerstones’
of welfare states and service societies; and subsequently, with the shifts
in the arrangements of welfare states (Hall and Soskice, 2001), and
new demands on health care, the professions are also undergoing
significant changes. As described elsewhere, “exclusion processes and
hierarchies within and between the professions have not been overcome.
However, their effectiveness is waning, [...] and new forms of
professionalism and ‘being a professional’ are beginning to emerge”
(Blättel-Mink and Kuhlmann, 2003, pp 14-15).
Transformations of professionalism intersect in complex ways with
shifts in gender arrangements.A classic pattern of professionalism based
on exclusion and hierarchy is closely linked to a gender order that
places men and masculinities in the first line; it is related to a ‘sexual
division’ of labour in health care (Parry and Parry, 1976; Witz, 1992).
This division is increasingly challenged, for instance, by new
professional projects of the predominantly female health occupations
and a growing number of women in the medical profession. Gender
is therefore an essential dimension when it comes to better
understanding the change and persistence of power relations in health
care (Davies, 1996; Riska, 2001a; Bendelow et al, 2002; Bourgeault,
2005).
Changes in health care are driven by various forces, which cannot
be assessed by simply looking at health policy and institutional
regulation. Next to economic constraints, major challenges facing
today’s health care systems lie, firstly, in a new balance between
professional independence and public control, secondly, between the
interests and social rights of participation of the various groups of
actors in health care, and thirdly, between the individual responsibility

5
Modernising health care

of the user and that of the welfare state towards its citizens. With
respect to health policy this approach towards professions helps both
to bring a broader spectrum of drivers and players into view that may
enable change, and to better understand the barriers towards integration
and policies introduced from the top down.

Towards context-sensitive approaches: professions,

the state and the public as a dynamic triangle
New forms of provider organisation, new actors – like the service
users and the various health professions – and new regulatory patterns
generate numerous shifts in the health care systems. For example,
hierarchies within the medical profession change when general care
is assigned a higher value than specialised care. Integrative models of
care promote the professionalisation of health professions and
occupations; these developments are closely linked to changing gender
arrangements.The implementation of market forces and managerialism
are further strategies that change the occupational structure and
professional identities of the medical profession and incite changes
within the ‘system of professions’ (Abbott, 1988).These developments
lead to a situation where the medical profession’s calls for autonomy
are confronted with the participatory rights of other health care workers
and the self-determination of the service users. Changes in work
arrangements are called for in this situation, as well as new strategies
of legitimising expert knowledge and new forms of building trust in
providers.
It must therefore be expected that the restructuring of welfare states,
epitomised currently by health care systems, will bring forth new
forms of professionalism, new strategies of professionalisation, and new
professional projects. Such developments cannot be grasped in terms
of ‘deprofessionalisation’ or ‘countervailing powers’ (Mechanic, 1991;
Light, 1995). Instead of clear effects, what we can expect to see
emerging are new tensions that provoke ongoing dynamics and new
uncertainties in the health system. Evidence from different health care
systems of the fluidity of professional boundaries (Saks, 2003b), the
flexibility of professionalism and professional identities (Hellberg et al,
1999) and hybrid forms of organisation and the context-dependency of
regulation (Dent, 2003; Burau et al, 2004) underscore the need for
both new theoretical approaches and comprehensive empirical analysis
in order to understand the dynamics and new dimensions of change.
One challenge to research is to disentangle global models and national
conditions, discourse and structural change, and the wide range of

6
 Introduction

interests of the players involved in health care systems. Modernisation

of health care systems does not simply work as a cascade of regulatory
incentives introduced from the top down and leading to frontline
changes in the provision of care. As Clarke and colleagues (2005)
argue, a conventional dualistic ‘from-to’ approach – from professionalism
to managerialism, from modernity to postmodernity, from self-
regulation to new governance and so on – is not convincing. My
contention is that a search for the tensions and dynamics ‘in-between’
these categories is a more promising approach.
Pursuing analysis across disciplines and pulling together different
theoretical approaches and research on the professions, health care
and social policy may further this search for a more dynamic approach.
The demands call for a method that leaves the trodden paths of linear
causal logic and instead explores specific ‘patterns’ (Abbott, 2001) or
‘maps’ (Burau, 2005) of change. In the present investigation I choose
an approach that identifies the ‘drivers’ and ‘enablers’ and the
‘switchboards’ of change in health care and then proceed to examine
the dynamics involved empirically (triangulation of methods; see the
Appendix). The design is based on four analytical steps and key
contentions (see Figure i.1).
The first step is to set out a theoretical framework that places change
in health care in the context of modernisation processes in society
and links the three arenas of change – state, professions and public.
The focus is on professions as mediators and change in this area (‘citizen
professionals’) in relation to new governance (‘state’) and changing
modes of citizenship (‘citizen consumers’). The aim is to show that
the transition from classical patterns of either state, market or corporatist
regulation to more flexible forms of new governance not only impact
on the professions in one direction, but also change the actual triangle
of professions, the state and citizens in complex and uneven ways.
The second step of analysis focuses, for the main part, on the linkage
between professions and the state, and maps out change on macro and
meso-levels of regulation; according to an understanding of governance
as a complex pattern of regulation, different dimensions are taken into
account (‘policy, structure, culture’). Set against the backdrop of
globalisation and European unification the boundaries between national
patterns of welfare state arrangements are increasingly fluid.Accordingly,
‘context’ cannot be defined merely in nation-specific ways. Analysis
of changes in one state needs to be placed in the context of European
health systems and global strategies of restructuring of health care, on
the one hand, and national transformations and pathways, on the other.
I start with, first, a rough plan of analysis of changes in health policy

7
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