Cash Limits, Hospital Prescribing and Shrinking Medical Jurisdiction

• Author: Christopher K. M. Pong,William J. Jackson,Audrey S. Paterson,Simona Scarparo
• Published date: 01 November 2014
• Date: 01 November 2014
• DOI: http://doi.org/10.1111/faam.12042

Financial Accountability & Management, 30(4), November 2014, 0267-4424

Cash Limits, Hospital Prescribing

and Shrinking Medical Jurisdiction

WILLIAM J. JACKSON,AUDREY S. PATERSON,CHRISTOPHER K. M. PONG

AND SIMONA SCARPARO∗

Abstract: In recent years substantial research effort has been applied to the study

of the introduction of accounting logics into medical practice, but little of that effort

has been applied to the area of the prescribing of medicines, especially in the hospital

setting. This paper uses the sociology of the professions as a lens to analyse how policy

and managerial initiatives promoting cost and budgetary concerns have affected

medical jurisdiction and prescribing practice within the setting of Scottish acute

hospitals. The findings suggest that the introduction of accounting logic is shrinking

medical jurisdiction and stratifying the profession within the hospital setting.

Keywords: cash limits, hospital prescribing, medical jurisdiction

INTRODUCTION

In recent years the attempts by government to redefine the boundaries

of authority within healthcare organisations have gained increasing traction

(Denis et.al., 1999, pp.104–5), and the traditional culture of professionalism

that underpinned organisations such as hospitals has increasingly come under

challenge (Brock et al., 1999, pp.1–2). Central to these changes are the

introduction of market-based reforms with new structures of accountability and

a heightened attention to ‘accounting logics’ (Broadbent and Laughlin, 1997).

These changes could be argued to have been aimed at and impacted upon the

medical profession. As Eve and Hodgkin (1997, p.74) have observed the medical

professionals had for long been a group that used ‘huge amounts of public

money’, but ‘barely had to account for their decisions’ and the reforms sought

∗The first and second authors are from the School of Management & Languages, Heriot-

Watt University, Edinburgh. The third author is from the Nottingham University Business

School. The fourth author is from the Deakin Graduate School of Business, Deakin University,

Melbourne, Australia.

Address for correspondence: Audrey S. Paterson, School of Management & Languages,

Heriot-Watt University, Edinburgh EH14 4AS, UK.

e-mail: A.Paterson@hw.ac.uk

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404 JACKSON, PATERSON, PONG AND SCARPARO

to address that situation. For example, major NHS reforms have resulted in

the inclusion of clinicians into managerial and financial management roles,

moving them more centrally into the organisation and its control systems

(Kitchener, 2000). As a result, professional activity is potentially affected in

all areas and a substantial body of extant academic research has grown up

around the analysis of these changes. However, the great scale and complexity

of healthcare organisation means that some areas of medical practice have been

relatively neglected in the accounting literature. One such area of neglect is

that of prescribing practice by clinicians; a fact which is surprising given the

scale of medicine cost to the NHS and the attention that has been paid to the

area by successive governments.

According to Britten (2001) pressures exerted by the state through the NHS

reforms and prescribing control initiatives have resulted in the prescribing

authority becoming a battleground in which clinical autonomy is vigorously

defended. This has arguably been exacerbated by the inclusion of medicines

expenditure into the overall cash limited budgets. Previously the exclusion of

medicines from the cash limit provided a safety valve for the unpredictability

of demand for prescription medicines, but now substantial cost variability has

been introduced which puts greater strain on clinical directorates and demands

greater attention to control. Additionally, a long series of government reforms

has aimed to put accounting rationales at the heart of prescribing through

the creation of overarching bodies that provide authoritative statements on

best practice based on cost as well as medical criteria. In the face of such

resource constraints and the increasing intrusion of cost and budgetary issues it

is unsurprising that doctors find themselves with reduced clinical freedom (Eve

and Hodgkin, 1997).

Undoubtedly part of the reason for this challenge is the position of remarkable

strength that the UK medical profession held in relation to control over its work.

The profession of medicine used medical discourse centred on the concepts of

safety and efficacy of treatment as a shield against intervention from managerial

concerns such as cost. Only clinicians it seemed were able to judge these matters

and non-medical concerns were held to be counter to the interests and needs

of the patient. Abbott (1988, p.47) observed that ‘most professions — American

medicine is the great exception here — have treatment cost as a central problem

in prescription’. In the past he could easily have added UK medicine to his

exception, but UK policy direction has for some decades tried to reverse this

attitude with substantial effort applied to areas such as prescribing. However,

only limited effort has been given to exploration of the effects of these accounting

discourses on prescribing practice and the work that has been done has focused

on primary rather than secondary care. By analysing the prescribing work of a

group of clinicians working in Scottish acute hospitals this study begins to fill

that gap. Using the lens of the sociology of the professions and in particular

the work on jurisdiction by Abbott (1988) the study examines changes that have

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