Open Access Research article

“A manager in the minds of doctors:” a comparison of new modes of control in European hospitals

Ellen Kuhlmann1*, Viola Burau2, Tiago Correia3, Roman Lewandowski4, Christos Lionis5, Mirko Noordegraaf6 and Jose Repullo7

Author Affiliations

1 Institute of Economics, Labour and Culture, Goethe-University Frankfurt, Frankfurt, Germany

2 Department of Political Science, University of Aarhus, Aarhus, Denmark

3 Department of Sociology, University Institute of Lisbon, Lisbon, Portugal

4 Voivodeship Rehabilitation Hospital for Children in Ameryka, Poland

5 Clinic of Social and Family Medicine, University of Crete, Greece, School of Medicine, Crete, Greece

6 Utrecht School of Governance, Utrecht, The Netherlands

7 Institute for Health, Carlos III, Madrid, Spain

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BMC Health Services Research 2013, 13:246  doi:10.1186/1472-6963-13-246

Published: 2 July 2013



Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals.


The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources.


The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management.


Our comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.

European Comparison; Hospital Governance; Doctors In Management; Professionalism; Cost And Quality Management; Coordination Of Control Modes