Unrecognised structural implications of casemix management

This paper takes issue with some conceptual and hence practical shortcomings which underlie current attempts to use casemix methodologies in bringing medical clinicians within the writ of management. The reform programme is grounded in an instrumental conception of organisation which construes the conduct and structuring of relationships in a hospital as being the product of its alleged purposive character and its formal design features. Accordingly, it is assumed that improving hospital efficiency and effectiveness requires no more than recasting formal authority structures and introducing information systems which will extend management's capacity to surveil and control the performance of clinical work. The paper argues that this conception of hospital organisation and what is required to achieve reform, ignores institutional pre-requisites which underpin management in industrial and commercial settings and denies evidence about a range of factors inherent in the prevailing organisation of medicine which militate against efforts to extend the writ of management over hospital-based medical work.