Constituting management requires more than creating hierarchy and providing information

Current efforts to realign authority relationships within hospitals are important, but not sufficient. The rules which underpin the autonomy of medicine and those which are required for constituting management in clinical settings are not 'things' which can be decreed in and out of existence either by altering the lines on a hospital organisation chart, or by improving hospital information systems and allocating managerial responsibility to some clinicians. Accordingly, the ultimate success of the current hospital reform program will depend on the willingness of players in health policy circles to broaden their reform agenda to encompass issues which go well beyond factors internal to the organisation of hospitals. Included here are initiatives in areas such as hospital casemix funding and budgeting; clinical protocols; establishing linkages between the managerial and clinical roles of clinician managers; and recasting the employment of hospital medical staff.