1
Bente Rasmussen,
Department of Sociology and Political Science,
NorwegianUniversity of Science & Technology, NTNU,
N-7491 Trondheim, Norway.
Power and freedom to manage? Governing by management agreements in public health and care services.
Paper to the International Labour Process Conference 2011, April 5th-7thLeeds.
Abstract
A central feature of the modernisation inspired by NPM has been to change bureaucratic organisations from imposing fixed rules to devolving responsibility for the public services and empowering staff to respond flexibly to user demands. In this process the role of managers is changing from a position in the professional hierarchy towards a position in the managerial hierarchy in line with the managerialism of NPM (Clarke & Newman 1997). Where the former heads of professional services should be loyal to public ethos, professional norms and bureaucratic rules, the new managers are made responsible to central management for delivering public services cost-efficiently.
In a study of women managers in the care for elderly (nursing homes and home-based care) in a two-tiered structure, we found that the delegation of power and responsibility to the local managers of nursing homes and home-based care was combined with increased central control of the budgets. The local managers were governed by management agreements where they accepted the conditions and negotiated (individually) the results that they were to achieve. Power and freedom to manage was conditioned upon their meeting the most important result; to deliver the necessary care within the budget. The managers of nursing homes therefore experienced power and freedomto manage becausetheir work load was limited by the available beds in the nursing homes and cutting the budget for nursing homes was a hot political issue. The managers of home-based care did not experience power and freedom, but increased control because they were responsible for all needs for care in their district, and their budgets could be cut when needs changed in other districts. Governing by delegating responsibility for results and individual management agreements can be understood as a neo-liberal form of government, offering the managers freedom and power, but only on the condition that they meet the demand of keeping within the budget. By delegating power and responsibilitythe local managers are made individually responsible for meeting the needs for care for the elderly, thus fostering a kind of governmentality as described by Foucault (2002).
Introduction
Public sector professionals have been characterised by a vocational commitment and an ethos of public service. Modernisation of the public sector inspired by ideas of New Public Management (NPM) (Hood 1991) aims to change this when managers are made responsible to central management for delivering public services cost-efficiently (du Gay 2007). Thereby management is changing from a position in a professional hierarchy to a position in a managerial hierarchy (CVlarke & Newman 1997). The new management positions are delegated power and responsibility for the services in exchange for their loyalty to the management of the city.
In line with the managerialism of NPM, the modernisation of public services in Norway decentralised responsibility to the service providers. The goals of the services were defined centrally, and local management was given autonomy to decide how to use their resources to reach the goals (Christensen & Lægreid 2001, Rasmussen 2004). Decentralisation and devolving responsibilities were the means to increase flexibility and empower the service providers to take the responsibility for meeting the needs of the public better. Whereas outsourcing technical services and infrastructure have been accepted, the privatisation of health and care services for the elderly has met with more resistance. It is upon this sector this study will focus.
In contrast to the introduction of general managers from outside the profession like in the UK, general or business managers were not introduced into the health care services in Norway. Managerialism was introduced as the ‘freedom to manage’ or the ‘right to manage’ for health professionals, empowering them as managers and offering release from bureaucratic rule. Thereby the management side of the tasks of the professionals in charge were enhanced at the expense of their professional tasks. The new management positions therefore changed the traditional professional position of nurse managers who had often been judged by their subordinates according to their willingness to be ‘one-of-the-girls’, and to lend a hand in practical bedside nursing (Davies 1995). The new management positions implied that they leave bedside care to their staff, becoming full-time managers of the health and care services.
While the early stages of modernisation in Norway were primarily concerned with increasing the quality of public services and tailoring them better to the needs of the users, the NPM aim of ‘getting more for less’ or ‘more value for money’ by slowing down or reversing government growth, became more prominent through the 1990s (Gullikstad & Rasmussen 2004). The task of the managers was influenced by this change, strengthening the focus upon cost containment and keeping within budget (Abram 2007). This was increased by the introduction of audits and user evaluations to secure the quality of the services that local government must answer for (Clarke 2005, Hammer 2004).
An earlier study of devolved responsibility to the care workers in public health and care services, showed that increased responsibility for the care of the elderly made work more meaningful for the workers, increasing their motivation and mobilising their effort to do a good job. The same study, however, indicated that increased responsibility without the necessary power over resources, was experienced as problematic for the professional managers of the services (Rasmussen 2004). When the city later removed all intermediate levels of management and administration and implemented a two-tiered structure under which the local managers of public services answered directly to the chief officer, the power over resources was again placed with the local managers. Local government thereby strengthened local management and emphasised that the managers should be trusted and have the freedom to make the necessary decisions to achieve their objectives.
The managers in the public health and care services were therefore faced with the task of shaping and delivering good health and care services for the public in their local community with the resources that were put at their disposal. In their role in the two-tiered organisation, they were given power over resources to manage this task. They were managed by management agreements, a form of contract that they individually made with the chief officer when they were appointed to their positions. This agreement described their area of responsibility, and the targets according to which their performance would be monitored and measured, were established in dialogue with the chief officer. By signing the agreement the managers accepted the conditions of their job; keeping to the budget, delivering good quality services and developing the services. What was their experience of the new empowered management position? Did it offer them freedom and power to managein line with the managerialism of NPM?
Power and freedom
The discourses of modernisation of the public sector and the new managerialism make a connection between freedom and power when local managers are promised power and freedom to manage. Scott (2008) distinguishes between two types of social power; corrective and persuasive influence. Whereas the first operates through punishments and rewards, the second depends on the offering of arguments, appeals and reasons to lead underlings to believe that it is appropriate to act in a certain way. The two main forms of persuasive influence are signification and legitimation, operating through shared cognitive meanings and value commitments, and these discursive meanings make a particular course of action seem appropriate (Scott 2008:30). Foucault (2002) uses the term governmentality to describe a type of persuasive influence defined as a specific combination of governing technologies and rationalities. According to Foucault this is typical of the modern, neoliberal period. Liberal governmental power operates largely through facilitative mechanisms rather than prohibitory, using institutionalised regulations through ideals, expectations, standards and frameworks which induce people to govern themselves in the ‘right’ ways:
A degree of freedom is implicit in the art of governing, in the liberal sense that the promotion of freedom, rather than its denial, is the most efficient way of achieving governmental ambitions (Allen 2003:80-81).)
Governmentality means both strategies of organisational governance and self-governance by those who are subject to governance. Liberal forms of governance therefore mobilise and include the personal ambitions of individual actors in the governance of organisations (Clegg, Courpasson & Phillips 2006:236). NPM is an example of neoliberal government aiming at changing bureaucracies from regulating conduct to govern through delegating responsibilities for results, recreating bureaucrats as entrepreneurial actors with power and freedom to manage, albeit in a responsible way, to meet the targets of the organisation. It empowers them, but at the same time subjects them to new strategies of surveillance and control (Clarke & Newman 1997). The dispersal of power can therefore be seen as a disciplinary strategy designed to constitute managers as self-governing actors, and when the strategies for self-governance are effective and the local managers are persuaded to do the right things, it becomes difficult to resist (Clegg et al. 2006).
The critique of the classic bureaucracy and the emergence of a new post-bureaucratic type of organisation suggest that power relations in the organisations are changing, producing flatter hierarchies and empowered workers. The public services remain, however, the responsibility of elected politicians at local and central level, and they are accountable for the performance of these services. They need, as a political body, to be able to show results (Hoggett 2005). Results are therefore increasingly measured in order to document the performance of public agencies (Clarke 2005). The contradiction inherent in the strategy of decentralising power to local managers of services while keeping central control of expenditure is managed by the introduction of indirect forms of government: the responsibility for the results of the services is delegated to local managers, while central authorities control the setting of standards, performance and budget (Clegg et al. 2006). Control by setting standards and budgeting is therefore an indirect way of managing and controlling professional workers (Ackroyd 1998). For managers in the public service sector, this results in particular tensions growing out of the contradiction in the degree of local autonomy and discretion that is promised in the decentralisation of responsibility on the one hand, and the central control on the other. The contradictions between promises of empowerment and experiences of centralised financial control, ensure that their identity is far from aligned with the discourse of a new and empowered managerial identity (Webb, 2006:93).
Power as relational
Here power is understood as a relational effect, and not as a property that can be held by someone or something. Power is dependent upon the contingent position of the agents involved in the specific relation. Local managers are placed in a hybrid relation to power: they are partly constituted by power and at the same time they are enacting it through their middle management positions which gives them power over their workers (Clegg et al., 2006). The local managers in public services are granted their power by central authorities and are subject to their demands, but to enact power, they are dependent upon the workers recognising their legitimate authority and being willing to do their best in order to deliver results (Lukes 2005). They thus have to fulfil the expectations from above to gain their legitimate power position (i.e. to develop the services and budget discipline), but to succeed in their position of power and deliver the expected results, they have to be granted power by the ones that theyhave been put in power over. Power in this sense, as the power to, and consequently the freedom to manage, is therefore not given by their management position.Understanding power as facilitative and relational,implies analysingthe power of the local managers in relation to their superiors and to their subordinates.
Technologies of power work in so far as they induce appropriate forms of conduct in those that they target (Clegg et al., 2006:230). The technologies in this case are delegating power to the local managers in a two-tiered structure, introducingmanagement agreements through which the local managers are governed, and the empowerment of workers (within the given resources). Power and freedom to manage has to be demonstrated by its effects in the relations where it is practiced. To analyse the power and freedom to manage for the local managers in the modernised public services, we therefore focus on these relations, and on the practices and effects of power of the local managers.
Method and data
To do this I use data collected in a qualitative study of the experiences of women managers with the two-tiered model in a large Norwegian city. The study was undertaken as part of a master’s degree by a former manager of health and care services in the city and a member of the chief officer’s staff (Nessæther 2007). The author supervised the study.
The sample was drawn from the largest public service in the city, the health and care services for the elderly and disabled. Home-based care was by far the largest of these services, followed by nursing home services. These services offered similar care but were organized very differently. Whereas a nursing home is a common spatial location for workers and patients in which the number of patients are more or less set by the number of available beds, home-based care is carried out in the users’ homes and the work-force scattered throughout the district that the unit serves. The workers in home-based care met at morning meetings, and sometimes also at lunch and in the afternoon. Their work load varied because they were obliged to provide services for all citizens in the area who needed it. When elderly people were taken ill or patients were discharged from the hospital, they became the responsibility of the home-based care units. These two types of health and care services were therefore doing the same type of work with a similar work-force, although under very different conditions regarding power over resources and responsibility for the services.This made it interesting to study the experiences of women managers in these two types of services.
Six women managers werechosen from home-based care, and four from nursing homes. They varied in age, work and management experience. All belonged to health professions and had at least three years of higher education (the majority were registered nurses). All were or had been married, and all had children.
The units in home-based care each had the equivalent of 30-50 full-time positions occupied by 70-90 workers, nearly all women. Home-based care employed registered nurses, enrolled nurses and skilled and unskilled care workers. Enrolled nurses and skilled and unskilled care workers were in the majority. The managers of the home-based care units had 4to 15 years of experience as managers. They varied in age from 35 to late in their 50s. Two had management training and several had not applied for the job, but had been offered the position as manager of the unit.
The nursing homes had the equivalent of 20-30 full-time positions which were shared by 50-70 workers. The nursing homes lacked registered nurses, but had a stable group of enrolled nurses and skilled care workers, nearly all women. The four nursing home managers were registered nurses and had from three to ten years of experience as managers: They varied in age from 35 to 55 years old. All had training in management. Most of them had had other management positions in the sector before, often in home-based care.
Each interviewlasted two hours and focused on the manager’s background and career choices, her experience as a manager, her relations with her subordinates and with her chief officer and other managers, her networks and her family in relation to her job.
We understand the qualitative interview as the co-construction of meaning in the relation between the researcher and the interviewees (Kvale 1994). In this study the researcher had intimate knowledge of the organisation and was known to the interviewees, but none had worked directly with her. The researcher was very conscious of her position as both a member of the chief officer’s staff andas a researcher doing her master’s project. In her staff positionher task was to give advice and control the local managers. Her framework of understanding the managers was that of the management tradition that analyses conduct as a result of personal traits and management styles. This was challenged in the research process where the focus was moved from ‘should have’ and ‘right ways’ to an analysis of their experience from the position of the local managers in the structural and political contextof the new management structure.