Time and Space in New Public Management Reform: The Case of Geriatric Care Hans Rämö Stockholm University School of Business
[email protected] Phone +46-8-16 12 09 Fax +46-8-674 74 40 SE-10691, Stockholm, Sweden and Per Skålén Karlstad University The Service Research Center
[email protected] Phone +46-54-700 2112 Fax +46 54-83 65 52 SE-65188, Karlstad, Sweden
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Time and Space in New Public Management Reform: The Case of Geriatric Care Structured abstract Research paper Purpose of this paper The implications of new public management (NPM) have been studied from several theoretical perspectives. The present paper argues that there is a missing dimension to the theoretical debate regarding NPM reform—that of time and space. On the basis of two different notions of time–space logics, the present paper develops a framework that contributes to a fuller understanding of NPM reform and organizational change/inertia in general.
Design/methodology/approach The theoretical framework of the paper draws on studies of time and space in organizations, research on public-sector reform, and neo-institutional theory. The empirical case study presented here focuses on an attempt to change geriatric care using NPM initiatives.
Findings The paper describes two paradigms of time–space logics—the paradigm of ‘speed’ (as used in finance and manufacturing) and the paradigm of ‘closeness’ (as used in health care and associated care-giving practices). The study argues that speed is a feature of almost all NPM programs, but that NPM programs are often directed at practices institutionalized by a time–space paradigm of closeness. The study utilizes the two time–space paradigms to understand the effects of NPM in the case reported. The use of time–space paradigms in studies of public-sector reform adds to the arsenal of theoretical tools for the analysis of NPM-reform.
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Research limitations and implications Although the methodology of a case study is an appropriate vehicle for introducing the time–space paradigm to this area of research, the methodology is not well suited to generalizing the findings to other contexts. Future research could elaborate on the present study by applying quantitative approaches to the subject matter.
Practical implications The study presents an analysis of an NPM-reform program in geriatric care—a context in which ideas of ‘speed’ clash with the traditional practice of ‘closeness’. This potential clash has important practical implications for managers.
Originality/Value The paper introduces notions of time and space into research on NPM-reform. This novel approach to the study of NPM reform might be of value in future research.
Key words: health care, new public management, time, space, reform, neo-institutional theory
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Introduction During the past two decades, many public-sector organizations in OECD countries have introduced new public management (NPM) change initiatives (Hood, 1991; 1995). Although some commentators have argued that NPM has had little effect on the structures and processes of organizations (Brunsson and Olsen, 1997), most scholars agree that NPM has had a significant impact (Denhardt and Denhardt, 2000; du Gay, 1996; Townley, et al., 2003; Power, 1997). NPM is a heterogeneous reform program that consists of a multitude of (sometimes contradictory) ideas—including total quality management (TQM), customer satisfaction measurement, decentralization of management authority, creation of quasi-market mechanisms, and cost control (Ferlie et al., 1996; Hood, 1991; Power, 1997). The aim is to produce a public administration in which ‘… the values of innovation, enterprise management and problem solving are paramount’ (Davies and Thomas, 2003, p. 682). The effects and implications of NPM have been studied and debated from several theoretical perspectives—including neo-institutional theory (Brunsson and Sahlin-Andersson, 2000; Hasselbladh and Kallinikos, 2000; Oaks et al., 1998; Power 1997), rationalization theory (Townley et al., 2003), power (Dean, 1995; Stokes and Clegg, 2002), interpretative approaches (Bevir et al., 2003a; 2003b), and Foucauldian approaches to subjectivity (Davies and Thomas, 2003; du Gay, 1996). Although each of these has made a contribution to an understanding of NPM reform, the present paper argues that there is a missing dimension to the theoretical debate regarding NPM reform—that of time and space. On the basis of the notion of time–space logics, the present paper develops a framework that can contribute to a fuller understanding of NPM reform and organizational change/inertia in general. The term ‘time–space logics’ is taken here to refer to different understandings of time and space in various organizational settings. Based on work within neo-institutional theory (Brunsson, 1993; Czarniawska and Joerges, 1996), the present study makes a distinction between ideas and institutionalized practice. Accordingly, it argues that all ideas that inform NPM contain certain elements of time–space logics that are fundamental to the various NPM ideas. In addition, practices are viewed as institutionalized by certain time-space logics which are fundamental to how they work and are perceived. The paper describes two
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particular paradigms (i.e. framework of thinking) of time–space logics—(i) the time–space paradigm of finance and manufacturing (referred to here as ‘speed’); and (ii) the time–space paradigm of health care and associated care-giving practices (referred to here as ‘closeness’). The study argues that speed is a feature of almost all NPM programs, but that NPM programs are often directed at practices institutionalized by a time–space paradigm of closeness. The empirical part of the paper is based on a three-year case study of an NPM-reform program within the Swedish health care sector. The NPM reform was especially focused on strategic development on the basis of business planning and quality management. The paper outlines the general ideas behind the reform program at the management level—with particular reference to the way in which a group of health-care personnel, particularly nurses, engaged in geriatric care interpreted the ideas driving the reform. Rather than using established theories for analyzing publicsector reform, the study utilizes the time–space logics framework to explore the potential conflict between NPM ideas of speed and practices institutionalized by closeness. The paper offers two distinctive contributions to existing knowledge. First, it adds to the arsenal of analytical tools available to assess NPM reform by introducing the perspective of time–space logics. Secondly, by developing and using a time–space framework, the paper presents a detailed analysis of the outcome of a particular NPM-reform program. The paper thus offers novel theoretical and empirical insights. The paper begins with a review of previous research on the subject of time and space in studies of public administration. The paper then develops a framework for considering time and space within the context of NPM reform. After explaining the methodology of the study, the paper then presents and analyzes a case study using time–space logics. The final section discusses the implications of the time–space framework for the study of NPM reform. The paper concludes with a summary of the conclusions and the contribution of the study.
Literature review and conceptualization
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Time and space in studies of public administration Before the 1980s there were few studies in the social sciences that dealt with time and space in organizations—apart from a few studies that alluded to the significance of time and location in terms of competitive advantage. In more recent years, the importance of time and space in the study of organizations has been recognized, even in studies that have not been primarily concerned with offering descriptive management models (Academy of Management Review, 2001; Adam, 1990; 1995; 1998; Castells, 1998; Cooper and Rousseau, 2000; Hassard, 2001; Kirkeby, 2000, Rämö, 1999; 2004; Zerubavel, 1979). In the extensive writings on NPM, few (if any) studies have explicitly examined the relationships among NPM, time, and space in any detail—although a few studies have made cursory mention of time and space in their analyses of NPM. For example, Miller and Rose (1990) spoke of two important dimensions of governmentality—sets of political rationalities and technologies of government (cf. Dean, 1994). The latter include systems of numbering, accounting, surveillance, expertise, organization of work, administration, and schooling, as well as methods of timing and spacing of activities in particular locales. Ellis (et al., 1999) studied how social-work teams, who were overwhelmed with decision-making needs, used various forms of frontline autonomy to handle their daily work and decisions—thus creating controllable time and space in which they operated. In a similar vein, Painter and Clarence (2000) discussed the ability of local authorities to operate in local ‘action spaces’, noting a tension between the demands of central government and the initiatives of the local authorities. Furthermore, Laughlin and Pallot (1998), drawing on Haas (1992), used the notion of ‘epistemic community’—a network of professionals in a particular domain with motive and opportunity to generate change at a particular level of government and public-sector organization. All of the above studies discussed various spatio-temporal matters, but none of them had a particular focus on time and space. It could be argued, however, that the core ideas of NPM— especially its focus on efficiency—intrinsically involve notions of speed (which implies notions of time and space). This paper therefore draws attention to this important spatio-temporal aspect of NPM.
The time–space logics framework
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A distinction is made in this paper between the management of time and space in industry and finance and that in health care (including nursing). The industrial and financial sectors usually revolve around questions of yielding return, where resources (denoted as 'capital' but usually reduced to money) will increase in the shortest possible time. The key notion in this management approach, which is referred to here as the time-space paradigm of ‘capital return’ is therefore speed. A faster return is generally considered better than a slower return. In parallel with this desire for greater speed, there is an imperative in the manufacturing sector to produce smaller entities that consume fewer resources—even to the extent that things cease to exist as physical entities (i.e. virtualization). 'Faster and smaller' has thus become the dominant paradigm in time-space logics—not only in finance and manufacturing, but in almost every profit-making relationship. This is evident in the management literature, were concepts such as Time-Management, Lean-Production and Just-In-Time (JIT) have become some of the most influential ideas (e.g. Stalk and Hout, 1990; Stern and Stalk, 1998). The focus has shifted towards paying homage to those who have been successful in cutting off yet another fraction of time in their ventures. The 24-hour, all-year-round, non-stop world of just-in-time manufacturing, trading and finance is today dominating in international business. This time-space paradigm of capital return is fully reasonable when it comes to, for example, the administration of financial capital. It is also entirely plausible to strive for smaller and faster technological applications and improved electronic communication. Whether we like it or not, miniaturization, virtualization and increased speed remain high on the contemporary management agenda. Speed is also the imperative in virtually every NPM idea. The main reason for this is that NPM has its origins in the private sector. Hood (1991, pp. 4–5) has argued that NPM consists of seven ‘doctrinal components’ of which at least four—‘explicit standards and measures of performance’; ‘greater emphasis on output controls’; ‘shift to greater competition in public sector’; and ‘stress on private-sector styles of management practice’—are clearly based on private-sector practice. The ethics of NPM are thus premised upon private-sector business values—such as functional rationality, costeffectiveness, and productivity (Denhardt and Denhardt, 2000; Pollitt and Bouckaert, 2000). Accordingly, NPM has been said to drive privatization, automation, and innovation (Christensen and Lægreid, 2001; Davies and Thomas, 2003; Hood, 1995)—concepts that are all clearly associated with
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private-sector industry and finance. A common denominator of these reforms derived from the private sector is their constant focus on cutting time in ventures. Health care (including nursing) has a different conception of time–space logics. Problems occur if the industrial/financial paradigm of return on capital and a desire for higher speeds is applied indiscriminately in health care. Although it is certainly possible to improve time-and-space efficiency in health care, such improvements are less likely to occur at the individual level. Rather, attempts to improve time-and-space efficiency in the healthcare sector are more likely to be effective in dealing with overall logistics and technological development. The potential to improve efficiency when providing individual health care for children, the elderly, the handicapped, or other special groups is less than the potential for efficiency in the industrial and financial sectors. Rather, the key concept in health care (including nursing) is the spatial property of closeness. Although telemedicine and other distance health services are becoming more common, physical closeness between an individual patient and an individual health care provider will remain a central element in most health care services in the future. To attend to other people’s recovery from illness and well-being normally requires the healthcare provider and the recipient to interact at the same time in a given location. Mobility and logistics in health care are supplied primarily by the employers while care and health recipients are proportionately immobile. The Swedish National Board of Health and Welfare (2001, p.160) touches on these issues of closeness in time and space in its discussion of the notion of accessibility. The concept of accessibility can divided into: (i) physical accessibility (which refers to the extent and localization of care); (ii) economic accessibility (which refers to the direct costs associated with the individual’s utilization of care); and (iii) time accessibility (which refers to the time before the individual actually receives care). The third of these, time accessibility, can be subdivided into: (i) direct waiting time (time in a queue); (ii) whether citizens understand how to use the healthcare system; and (iii) whether medical care is capable of meeting various care needs (conceptual accessibility). In health care, there is also frequently a discrepancy between the provider’s view of the expected services and the recipient’s view of those services. In simplistic terms, there is insufficient time for those who provide health care, whereas, for the recipients of health care, there is an excess of 8
time (often spent in long waiting times before they receive health care). Consequently, there is a scarcity of time and spatial nearness for those who provide health care, but an abundance of meaningless time and separateness among the recipients of care. Against this background, although well-known NPM concepts—such as purchasing, contracts, efficacy, productivity, and budgetary responsibility—have become common within the healthcare sector, such financial considerations create resource restrictions in time and space. This, in turn, results in time shared with care recipients becoming less of an imperative than other logistical tasks—such as the management of food services, hygiene services, and necessary medical measures Health care is thus exposed to rationalization pressures on two fronts. There is pressure from health care management, employers, and economists who wish to see the organization run as effectively as possible—with effectiveness being principally measured in monetary terms. On the other hand, there is increased demand for personalized health care services—in part because of increased individual incomes, and in part because of the demographics of an ageing population. There is less potential for rationalization within personnel-intensive sectors (such as health care) than in technologically intensive sectors. Health care will continue to require a great deal of time and space, and will therefore continue to be relatively more expensive than other sectors (cf. Baumol’s law, 1967).
Case study Methodology The methodological approach in the present paper was that of a single case study. The principal aim of a single case study is not to make generalizations, but rather to present a description of a particular empirical situation. An important function of case studies is to illustrate the value and originality of a particular theoretical framework (Yin, 1984). Accordingly, the case presented in the present paper has an illustrative function in introducing the utility of a time–space framework in research into publicsector reform. However, as Yin (1984) maintained, it is possible to generalize from a single case study—not by statistical generalization, but through analytical generalization. When the latter form of generalization is utilized ‘…a previously developed theory is used as a template with which to
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compare the empirical results of the case study’ (Yin, 1984, p. 31) and thus to support and develop its claims. In the discussion towards the end of the present paper, an effort is made to generalize analytically from the case by comparing the study to the theoretical framework described above. In the present study, three data-collection methods were used. Such a triangulation approach to the empirical work is a major strength of the case-study design (Yin, 1984). The data-collection methods for the present study included: (i) participant observation of meetings held by the group studied; (ii) interviews with six members of the group; and (iii) collections of written documents from the group (for example, different versions of the business plan they developed).
Background to the case study The empirical case study presented in the present paper focuses on an attempt to change geriatric care at the County Council of Värmland (CCV), the public health care authority for the region of Värmland, in western Sweden. It formed part of a more comprehensive empirical case study of organizational reform that was aimed at reshaping the whole CCV and which lasted for almost twoand-a-half years (from November 1998 to January 2001). To accomplish this change, the organization was divided into work groups that were responsible for writing a business plan for their specific area of responsibility. The present study focused on the group responsible for developing geriatric care. This study lasted from December 1999 to September 2000. The public health care system is an important part of the established Swedish welfare state. More recently, private alternatives have been launched, but the public health care system dominates. The private alternative is basically confined to smaller units, such as care centers. The Swedish public care system is organized into 28 geographical regions—with county councils (CCs) forming autonomous administrative units. The CCs are complex organizations with each having a political assembly, an administration, and a medical service. Medical services include various specialities (for example, psychiatry and surgery) and various categories of personnel (for example, nurses and doctors). According to the Swedish doctrine of public administration (Lundquist 1998), politicians are responsible for policy-making, administrators are responsible for policy implementation, and the medical personnel are responsible for providing the actual health care services. The Swedish Health
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and Medical Service Act (SFS 1982:763) provides a framework for the organization of CCs, but within that general framework each CC has significant freedom to decide how it wishes to organize itself. In the CCV (the CC focused upon in the present paper), a geographically dispersed organization with five hospitals had been established. The reform at the CCV started when a new director was appointed at the end of 1996. She believed that the CCV was an outdated organization that had (unlike many other CCs) not adopted modern management techniques—such as NPM initiatives. The director had significant influence with politicians who became convinced that it was time to do something radical with the organization. Accordingly, they ordered the director to devise a plan for reorganization. The director formed a working group with representatives from administrative and health care personnel. This group eventually developed an ambitious business plan that was informed by NPM ideas, particularly quality management (Ferlie et al,. 1996) and business planning (Oaks et al., 1998; Townley et al., 2003). The plan had three main goals: (i) satisfied customers/patients; (ii) satisfied personnel; and (iii) balanced finances. The organization was also to be process-oriented—with the main work-flows of the organization being mapped out from a customer perspective and these processes functioning as a baseline for understanding how the organization really worked. To create an organization that satisfies its customers—that is creating a customer orientated organization—is the most important goal with quality management. Process-orientation is the most frequently used technology to accomplish this (Hackman and Wageman, 1997). The business plan also suggested that work groups should be responsible for carrying out these developments. These work groups (known as ‘process groups’) were to be formed around different patient groups and/or diagnoses, and were to write business plans that implemented the overall business plan in their specific areas of responsibility.
Findings The process group responsible for developing geriatric care was the focus of the present study. This group met for a total of 10 days before it had completed its business plan. The group had 29 members and was chaired by an experienced nurse. Most of the members were women (four were men) and nurses (three were doctors). The members came from all five hospitals within the CCV and from the
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various municipalities within the region. The group was to follow a specific strategic-development model when conducting its strategic development and writing its business plan. This model consisted of six steps: (i) background; (ii) goals; (iii) success factors; (iv) aim; (v) activities; and (vi) personnel and organization. The model thus had much in common with original strategic-development models (e.g. French, 1969).The present study concentrated on the aim, success factors, and goals of the group’s plan. In formulating an aim, the members of the full group worked in smaller groups. Discussion in all groups centered on how to create a better life for the patient and how this should be achieved. Some believed that it was important to work in teams—because elderly patients often have multiple problems and are therefore in need of attention from several specialists. Others believed that the patients’ pathways should be defined more precisely. The final aim was expressed as follows: By adopting a teamwork approach we shall create a base for developing a clear patients’ pathway, containing diagnostic and rehabilitation procedures, treatments, and care adapted to the needs of the elderly in order to satisfy individual needs.
It is interesting to note that the discussion and final aim of this group focused on only two of the three goals of the overall business plan. The group aimed to satisfy the needs of patients and personnel. The third goal of the overall business plan—balanced finances—received little or no attention. Although the group developed its aim fairly easily, it had more difficulty in identifying success factors. This was because the members did not know what was meant by the term ‘success factor’. According to the overall strategic-development model, success factors were defined as attributes that needed to be present if the aim and the goals were to be achieved. The process group worked on the question of success factors at several meetings in small groups. Each small group spontaneously divided potential success factors into success factors for patients and success factors for personnel. Again, the focus was on only two of the overall goals—with the success factors dealing only with satisfied personnel and satisfied patients. Success factors for balanced finances were not considered. Having a ‘comprehensive view’ was the one success factor that was central in the discussion from the very start. Adopting such a view is a fundamental competence in elderly care and
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encapsulates the essence of geriatric care. As a member of the group explained it, according to such a perspective, elderly people should not be considered as ‘a bad knee’; rather carers ‘have to take into account the whole human being’. A comprehensive view thus refers to the ability to see the whole of a complex clinical picture in caring for elderly people. If personnel have this ability, group members were convinced that the patient will be more satisfied. Personnel thus saw themselves as a means of pleasing patients. However, the personnel argued that providing satisfaction to patients also satisfies personnel. In addition, as one group member observed, it is ‘more fun to work with happy people than depressed individuals’. There is thus a positive relationship between satisfied personnel and satisfied patients in geriatric care. It should be noted that balanced finances have no place in this assessment. In fact, sounder finances might be counterproductive to the goals of satisfied patients and personnel because approximately 80% of the costs in Swedish health care are personnel costs (The Swedish National Board of Health and Welfare, 2002), and sounder finances might imply fewer personnel. According to the members of the group, fewer personnel implies inferior care quality—because care of the elderly ‘takes time’ (as one group-member put it). The group finally decided that the main success factors were ‘a comprehensive view’, ‘competency’, ‘responsiveness’, and ‘cooperation’. Most group members also had difficulty in formulating goals. The main reason was that the overall reform plan decreed that these should be ‘measurable’, and most members were not used to thinking in such terms. The work with goals paralleled the work with success factors, and lasted for several meetings. The group identified 13 factors to ‘strive for’—rather than specific measurable goals. None of these addressed financial issues; rather, they addressed topics such as the involvement of the patients’ close relatives, the development of home care, the development of teamwork, and an improvement in the qualifications of personnel. The chairman explicitly acknowledged the failure to address financial goals during one meeting when she observed that ‘the goals contribute to … satisfied patients and satisfied personnel, but not to balanced finances’. One group member responded to the chairman by noting: ‘I believe that the patient should be given priority’, and a second group member gave her support to that view: ‘It is natural for us to center on the patient’.
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The lack of attention given to financial issues was also evident in the suggestions provided with respect to activities, changes in personnel, and the form of organization: these areas were also only approached from a patient and personnel perspective. Reflections on the business plan Politicians and administrators were invited to the group to comment on its work during and after the group’s deliberations on the business plan. A common observation among these visiting politicians and administrators was that the group had given priority to fulfilling the goals of satisfied patients and personnel, to the detriment of achieving balanced finances. As one administrator observed: ‘You haven’t cared much about money in this group, have you?’. Interviews with six of the group members (after the business plan had been completed) confirmed that the financial goal had been downplayed. As one nurse commented: The patients should be given priority because they are human beings in need. The personnel come second because we are also human beings. I also know that satisfied personnel contribute to the goal of having satisfied patients. The financial goal, however, is a bit distanced from the other two and it is not very common among the personnel to discuss financial issues, because someone else usually takes care of such matters.
It is also apparent that the process orientation of the enterprise—another important goal in the comprehensive business plan—was downplayed. The members of the group were assigned to produce one process map for each of the five hospitals. Only two (out of five) such maps were produced. The group allowed only one hour for the presentation and discussion of these maps, and the maps had no impact on the business plan. In the interviews conducted with some members of the group it was apparent that most of the members had a poor understanding of process and process orientation. As one nurse observed: Process is a word that is used by many people. It is a process, it takes time, and the process has to take time. It is a word that we make use of but we never really consider what we really mean with it. ‘Process’—I view it as a development—maybe synonymous with something’s happening, something starts, and develops to something else.
Analysis
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The work of the process group for geriatric care focused on meeting two goals—satisfied patients and satisfied personnel. However, the group’s work did not contribute to meeting the financial goal of the business plan, and also failed to contribute to the creation of a process-oriented organization. This can be analyzed by drawing on the time–space logics outlined above. As previously noted, practices of geriatric care is institutionalized by a time–space logic that can be referred to as ‘closeness’. Elderly care usually requires personnel and patients to interact at a given time and in a given location. It is difficult to speed up the work tasks—such as feeding and dressing— that characterize geriatric care. In addition, as previously noted, there exists a positive relationship between satisfied personnel and satisfied patients—in that satisfied patients contribute to the satisfaction of personnel, and vice versa. To accomplish this, given the task structure, the relationship between personnel and patients must be defined within the boundaries of the ‘closeness’ of time–space logics. There also appears to be a positive relationship between process orientation and balanced finances. The rationale behind process orientation was to make the ‘flow’ of patients visible in the organization, and thus to expedite bottlenecks by standardizing each individual case to the most effective process flow. This enables managers to reduce personnel and thus cut costs. Process orientation and balanced finances are thus premised on the logic of return on capital and the desire for greater speed. However, the paradigms of ‘closeness’ (satisfied personnel and patients) and ‘speed’ (balanced finances and process orientation) are often incompatible. Because the bulk of the cost in Swedish public health care is due to personnel costs, the objective of ‘sounder finances’ implies, in simple terms, a reduction in personnel. However, because the quality of geriatric care is premised on the time–space paradigm of ‘closeness’—that is, a close, intimate, and trusting relationship between personnel and patient—reduction of personnel reduces the quality of care. It is therefore apparent that the ‘closeness’ aspect of the reform idea—satisfied patients and satisfied personnel—is compatible with the institutionalized practice of geriatric care, whereas the ‘speed’ aspect of the reform idea— balanced finances and process orientation—remains incompatible. As might be expected, none of the members of the process group for geriatric care talked about the reform dynamics using the language of time–space logics outlined here. Nevertheless, although 15
they did not articulate it explicitly, all members of the group were implicitly aware of this dynamic. Their failure to articulate their views probably reflects the institutionalized nature of the ‘closeness’ paradigm in geriatric care. Institutions are deeply embedded social structures, meaning that actors rarely discuss or reflect upon institutional arrangements in an explicit fashion; furthermore, institutions have a persuasive impact on the thinking and actions of those involved (DiMaggio and Powell, 1991; Meyer and Rowan, 1977). The implication of this for the present case is that every member of the process group appeared to hold a similar (if tacit) understanding of the reform ideas. This understanding was formed under the influence of the institutionalized action and thought structures of geriatric care. The members of the group did not therefore find the NPM-reform program very attractive. Indeed, they did not perceive the ‘speed’ aspects of the reform program as being at all useful, and they barely mentioned the associated issues of balanced finances and process orientation. Rather, they interpreted the reform program in accordance with their institutionalized organizational practice and thus believed that it primarily offered an opportunity to improve the satisfaction of patients and themselves.
Discussion and contribution The analytical framework of time and space presented here contributes to the study of public-sector reform. Health care activities characteristically take time and demand space. Everyday nursing activities involve ‘micro meetings’ for the daily private management of such things as food and hygiene. An asymmetry of expectations can therefore easily arise. In contrast to service production in general—with two active partners in a buyer–seller relationship—health care is about the relationship between a weaker (exposed) party and a stronger (benevolent) party. The asymmetry between the partners in health care means, in the words of Hirschman (1970), that ‘exit’ is more difficult, ‘voice’ is courteous, and ‘loyalty’ is absolutely dominant (although it might be a forced loyalty in some situations). Health care activities cannot therefore be rationalized to the same extent as can be achieved in industrial production or in ‘typical’ service production (such as banking, insurance, and so
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on). In health care, speed is restricted by the recipient’s restricted perception (because of age, handicap, or illness). Moreover, in health care, centrally imposed demands for good care and good economy can be perceived as unreasonable—given local circumstances in daily operations. Local circumstances often mean that central decision-makers are forced to relax their demands for efficiency. In addition, there is often a gap between the expectations of personnel with respect to the health care procedures that are to be carried out and the care recipient’s expectations of the same situation. This expectation gap is widened when both partners feel dissatisfied with the situation because of the obvious time pressures that are placed upon them by management or by the responsible authority (such as the CCV). In terms of the logics of time and space discussed above, the conflict is intensified if the emphasis on ‘speed’ becomes the dominant paradigm at the expense of health care’s traditional emphasis on the time–space paradigm of ‘closeness’. This paper presents empirical evidence of NPM-reform work within the process group charged with geriatric care at the CCV in Värmland, Sweden. The paper shows that this reform work created a tension between the principal commissioning body’s demand for increased financial effectiveness and the health providers’ desire for good care. This tension has been analyzed with a particular focus on time and space in which financial effectiveness is posited as being dominated by ‘speed’ whereas good care is dependent on ‘closeness’. Whether health care is managed and financed privately or publicly, the paper suggests that the tension generated by the different time–space logistical paradigms remains problematic, and that these problems are relatively little studied and poorly understood. These problems are not unique to geriatric care. Other health care specialties—such as psychiatry, child care, and so on—face similar problems when NPM reforms are introduced. This study’s focus on the problematic relation between a desire for increased ‘speed’ (in the paradigm of return on capital) and a desire for ‘closeness’ (in the paradigm of traditional health care) adds to the arsenal of theoretical tools for analysis of public-sector reform.
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