Clinician responses to management control: Case evidence from a university hospital during the fiscal crisis

• Published date: 01 August 2020
• Author: Matthias P. Beck,Michelle Carr
• DOI: http://doi.org/10.1111/faam.12224
• Date: 01 August 2020

Received: 28 September 2017 Revised: 17 June 2019 Accepted: 26 June 2019

DOI: 10.1111/faam.12224

RESEARCH ARTICLE

Clinician responses to management control: Case

evidence from a university hospital during the

fiscal crisis

Michelle Carr Matthias P. Beck

Department of Accounting and Finance,

University College Cork, Cork, Ireland

Correspondence

MichelleCarr, Department of Accounting and

Finance,University College Cork, Cork T12 K8AF,

Ireland.

Email:m.carr@ucc.ie

Abstract

Ireland experienced a major fiscal crisis from 2008 to 2013. This

paper explores clinician responses to crisis-related control initia-

tives at one of Ireland’s largest university hospitals. Using qualita-

tiveresearch methods within an interpretative framework, our study

suggests that some clinicians responded with antipathy, whereas

othersattempted to engage with managerial demands. Usingnotions

of organizational and occupational professionalism, we link the

observed heterogeneity of these responses to factors such as the

perceived usefulness of control information, the clinician manage-

ment relationship, and the clinicians’ specialism. Our analysis sup-

portsa nuanced interpretation of clinician behavior where their posi-

tionalong a continuum from resistance to collaboration is affected by

group characteristics and beliefs as well as the way control informa-

tion is collated and disseminated. These findings have implications

for the implementation of control measures in various contexts.

KEYWORDS

clinicians, fiscal crisis, management control, new professionalism,

new public management

1INTRODUCTION

Over the past decade Ireland experienced one of the worst boom to bust cycles affecting developed countries since

the Great Depression (Burke,Thomas, Barry, & Keegan, 2014; Callan, Nolan, Keane, Savage, & Walsh, 2013). The ensu-

ing fiscal crisis forced the country to accept a bailout that led to a 20% decrease in hospital funding from 2008 to

2013 (Health Service Executive [HSE], 2014). During this period, hospital management control systems, which had

been introduced in 2004, became one of the main transmission mechanisms through which cuts were implemented.

This paper reports on clinician responses to these measures based on a 3-year longitudinal study of one of Ireland’s

largest university hospitals during the crisis years. Our clinician sample includes consultants who acted as chairs of

Financial Acc & Man. 2020;36:319–337. wileyonlinelibrary.com/journal/faam c

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320 CARR ANDBECK

their division and consultants who worked in the same area of specialism. Additionally,we report on the views of exec-

utive and senior management, such as the hospital’s head of IT,whose perspectives help evaluate clinician reactions.

Our research relates to the literature on how clinicians, as a professional group, adapt to management control

in different times and contexts (De Harlez & Malagueno, 2016). It also offers a window into professionals’ atti-

tudes toward the perceived adoption of New Public Management (NPM) style control measures during a crisis, in

line with U.K. research in this area (Hyndman & Lapsley, 2016). Conceptually, we employ the literature on clinician–

management relationships (Numerato, Salvatore, & Fattore, 2012) and new professionalism (Evetts, 2010; 2011) in

order to exploresome of the factors, which encourage and discourage clinicians from becoming “talking professionals”

who actively engage with management control initiatives, in the hope that this offers insights into the possibility of

inter-professional dialogues during crisis periods.

Our paper is structured in five main sections. Section 1 discusses context. Section 2 explores linkages between

the sociological literature on clinicians as professionals and prior work on management control in hospitals. Section 3

describes our research methodology, whereas Section 4 reports findings from our qualitativedata analysis. Section 5

applies concepts of professionalism discussed in Section 2 to findings from our data analysis.

2ECONOMIC AND INSTITUTIONAL CONTEXT

Over the past 30 years the control of clinical practicein the Irish healthcare system has undergone extensive changes.

In common with other countries, pressures for greater efficiency and accountability derived from demographic and

structural developments such as an ageing population, autonomous increases in healthcare demands, the impact of

new pathologies and technologies, and publicly exposed clinical failures (Cardinaels & Soderstrom, 2013; Chapman,

Kern,& Laguecir, 2014; Kurunmäki, Lapsley, & Melia, 2006). Although Ireland initially coped well with these challenges,

this changed dramatically during the 2008–2013 financial crisis.

Thecombination of the global economic recession, the banking crisis, and the collapse of a domestic property bubble

led to a fiscal crisis where Ireland had to accept a €85 billion bailout from the so-called Troika(ECB, EU, and Interna-

tional Monetary Fund [IMF]). In 2009, the IMF noted that Ireland “was perhaps the most overheated of all advanced

economies” (IMF,2009, p. 5) and described the Irish crisis as matching “episodes of the most severe economies in dis-

tress in post-world war II history” (IMF, 2009, p. 28). As a prerequisite of the 2010 bailout, Program Documents set

requirements for a reduction in deficit to 7.5% of GDP by 2013 and to 3% by 2016 (Department of Finance, 2010).

The IMF identified cuts in healthcare expenditure as critical to the attainment of these requirements (IMF, 2010,

p. 6). Budget targets included a 12% reduction in healthcare expenditurefor the period from 2008 to 2013 (HSE, 2014),

which entailed a fall in hospital funding of 20%. By December 2013, about 12,000 fewer individuals worked in Irish

healthcare than in 2007 (HSE, 2013). International comparative work suggests that of all 53 World Health Organiza-

tion (WHO) countries, Ireland experiencedthe greatest drop in health spending from 2008 to 2013 (Burke et al., 2014;

Turner,2018).

As the Irish government sought to improve efficiency in healthcare delivery in response to the crisis, clinician

engagement was seen as central to intended reforms. This focus on clinicians related to legacy issues dating back to

the 1990s. Until the late 1990s, clinicians dominated hospital decision-making with hospital managers acting largely as

subordinates. Managerial control was limited primarily to nonclinical and support functions and to capital expenditure

decisions. Hospital management, devoidof external accountability, played a liaison role with the Department of Health

and Children (DoHC) from which they frequently sought additional resources in response to clinician-induced bud-

getary overruns. Within this modus operandi rationing was uncommon and clinicians were allowed to treat patients

largely as they saw fit.

In 1994, the government outlined a new vision for managerial roles in hospitals in the strategy document “Shaping

a Healthier Future” (Department of Health and Children, 1994). This document highlighted a need to involveclinicians