Abstract
New public management accountability is increasingly being introduced into health-care systems throughout the world – albeit with mixed success. This paper examines the successful introduction of new management accounting systems among general practitioners (GPs) as an aspect of reform in the Italian health-care system. In particular, the study examines the critical role played by the novel concept of an ‘ethical budget’ in engaging the willing cooperation of the medical profession in implementing change. Utilizing a qualitative research design, with in-depth interviews with GPs, hospital doctors and managers, along with archival analysis, the present study finds that management accounting can be successfully implemented among medical professionals provided there is alignment between the management imperative and the ethical framework in which doctors practise their profession. The concept of an ‘ethical budget’ has been shown to be an innovative and effective tool in achieving this alignment.
Introduction
The health-care sector is under pressure in many countries to contain expenditure, despite the increased demands placed upon health-care providers by ageing populations and rising expectations. One response has been the adoption of new public management (NPM) techniques and private-sector accounting tools. 1 However, such changes in management practice can have unpredictable outcomes, especially when the changes impinge upon the distinctive values and work practices of health-care professionals. 2,3
An innovative response to this situation is the adoption of what this paper refers to as an ‘ethical budget’. Such an ‘ethical budget’ aims to address the difficulties that cause concern to doctors who are faced with potential clashes between their professional values and the demands of budgetary accountability. Ethical budgeting, which is based upon a ‘higher principle’, 4 facilitates the acceptance of budgetary principles among health professionals. The present study uses a qualitative case-study approach to examine the introduction of budgeting among Italian general practitioners (GPs) within a context characterized by historical hostility to the introduction of new accounting methods.
Management accounting in the health-care sector
Many countries have introduced NPM and management accounting in the public health-care sector with the aim of controlling expenditure. 1 However, the introduction of such managerial tools in a medical environment has often been attended by difficulties. Budgetary control in the health-care sector has often been confounded by the ‘ritual, myth and ceremony’ that is associated with professional medical practice. 5
In the UK, various business-management techniques have been introduced, including performance management, competitive tendering, cost-improvement programmes and ‘value for money’. 6 In other countries, such as the USA and Australia, such business-management techniques as ‘case-mix analysis’ and ‘diagnostic-related groups’ have also been introduced. According to Hood, 1 the overall aim of all of these changes has been to introduce a ‘market culture’ into the public health-care sector, although the diffusion of these initiatives has varied among different countries. 7–9
A study by Jacobs 10 suggested that primary care GPs can respond positively to new accounting techniques if they are actively involved in the implementation of the system. Similar observations have been made with respect to doctors who are involved in secondary care. In contrast, numerous studies have emphasized the strong opposition of doctors to managerial changes that are introduced without their involvement and consent. For example, Jacobs found that hospital doctors in New Zealand perceived that new managerial arrangements threatened to reduce their control over clinical decision-making; as one doctor commented: ‘… management doesn't appear to have patient or staff goodwill at heart’. 11 In a study of the UK health system, Thorne 12 reported that some clinicians had taken on the role of ‘clinical directors’ in order to maintain control and protect their colleagues from what they perceived to be extensive managerial intrusion. Thorne characterized these developments as medical professionals ‘colonizing’ managerial functions in an attempt to mitigate the so-called ‘managerialism’. In a New Zealand study, Doolin 13 contended that the engagement of doctors in the case-mix system had mitigated feelings of losing power and influence. Research by Jacobs et al. in Germany, Italy and the UK has confirmed Doolin's view that doctors are perfectly capable of understanding new processes – although, in some cases, they have considered the information irrelevant. 13,14 This was also the case when budgetary controls were introduced in a Norwegian university hospital; these controls had a limited impact on clinicians, who perceived the budget as not capturing the distinctive nature of medical activity and, therefore, as being irrelevant. 15 In this case, the clinical manager justified budgetary deficits, which undermined the aim of the exercise. In this regard, Abernethy and Stoelwinder 16 have noted that imposed budgetary caps tend to be rejected by medical professionals – unless the budgets are devolved to professionals who feel empowered by the process. However, as Blomgren 17 has noted, devolution to a particular group of professionals (such as occurred with the so-called ‘administrative nurses’ in Sweden) can cause other groups of professionals to perceive that the budgetary reform process threatens their own professionalism.
In summary, it seems that new accountability standards will be accepted by groups of professionals if they perceive that the new arrangements enhance their power and visibility within their working system. However, a similar degree of acceptance is unlikely to be forthcoming from professionals who fail to perceive these potential benefits. Thus, although the studies reviewed above suggest that accounting innovations are likely to be resisted by medical professionals, the extent of the resistance appears to depend upon how the innovation is implemented.
Research context
The Italian National Healthcare System was reformed in 1978, when it replaced an insurance-based system. The reformed system offered uniform health care to all citizens. Patients registered with GPs, who acted as gatekeepers to the system; however, unlike the UK National Health Scheme, a GP referral letter enabled Italian patients to choose a registered (public or private) specialist. Local health-care units (Unità Sanitaria Locale) had a geographically defined area of responsibility for health care (both primary and secondary). Within some regions, local authorities devolved aspects of their social care responsibility to the local health authority (LHA), thus forming local social-health-care units (LSHUs) (Unità Socio-Sanitaria Locale). Most resources were allocated to the regions from the National Healthcare Fund on the basis of defined criteria, including demographic profiles and population densities.
Further health care reforms were undertaken in 1992. 18 These reforms aimed to: (i) introduce management accountancy techniques; (ii) shift some financial responsibility from central government to regional government; and (iii) change the previous system of historic budgeting without penalty for accumulated deficits. The LSHUs were redesignated as social-health care authorities (LSHAs/LHAs) (Azienda (Socio)/Sanitaria Locale). Specialist regional and national hospital trusts (Azienda Ospedaliera, AO) were designated in each region. In some regions, only a limited number were so designated (for example, two in the Veneto region), whereas in others (for example, in Lombardy) all hospitals were designated as AO.
Under the 1992 reforms, each region appoints a chief executive officer (CEO), who is responsible for ASSL and AO performances. The CEO appoints three directors who are responsible for medical, administration and social issues, respectively. The CEO has managerial powers and can be dismissed if budgets are exceeded or performance targets are not met. Each ASSL or AO is obliged to use accrual accountancy to balance budgets, and the region has responsibility for monitoring deficits. Further reform was undertaken in 1999, which recognized the central role of district levels in integrating social and medical care at the primary level.
GPs play a crucial role in this structure. Since 1978, GPs have enjoyed the status of independent contractors with the LSHAs, and have been accorded the power of gatekeepers. Their contracts are based upon a model three-year national agreement between the government and GP professional associations (‘trade unions’); few GPs work outside this arrangement. In recent years, there has been a trend towards the creation of GP networks and closer integration with home-care services, whereas previously all GPs used to work in single-person practices, without nurse assistants.
Research methodology
Research setting
A qualitative empirical case study was conducted between 1999 and 2004 at a selected Italian LSHA to which the present author was granted full access. This LSHA, known as the Azienda USSL 4 ‘Alto Vicentino’, Thiene, is one of 21 LSHAs located in the Veneto region of north-eastern Italy. This LSHA had exceeded expectations by successfully introducing innovative managerial tools within an organization that was strongly influenced by the medical profession. Although the organization had experienced financial difficulties in the early 1990s, performance had subsequently improved to the extent that it was performing better than other regional LSHAs, according to later financial data.
The major innovation had been the establishment of a cooperative relationship between GPs and the LSHA management during the introduction of new managerial tools. This had occurred at a time when GPs had minimal interaction with the LSHA management. The objective of the present study was to identify the factors that facilitated this changed relationship between doctors and managers.
Data collection and analysis
The methodology adopted for the study consisted of a ‘grounded theory’ approach, which aimed to gain insights into the challenges that the LSHA faced, and the actions that it took in response, over several years of managerial and budgetary change. 19,20 Data were mainly collected through 18 semistructured interviews with GPs and other relevant actors, who had been involved in the process, between 2000 and 2004. In addition, documentary data covering the period from 1996 to 2004 were also thoroughly analysed. These documents included: (i) minutes of meetings; (ii) documents distributed to meeting participants and other interested parties (for example, GPs); and (iii) miscellaneous documents (letters convening meetings, various internal communications, publications and the proceedings of a conference). In most cases, archival analysis preceded the interviews, which facilitated investigations of the perceptions of interviewees in relation to various developments.
Findings
The concept of an ‘ethical budget’
In 1992, the LSHU in the Veneto region recorded the largest accumulated deficit of all Veneto LSHUs, prompting management to inform its staff of a rapid deterioration in the organization's financial position. Nevertheless, little changed, and continuing deficits led to the appointment of an ‘enactment commissioner’ by the regional government. Subsequently, after taking some unpopular decisions (such as reducing services), the ‘enactment commissioner’ resigned.
Management then decided to attempt to bridge a perceived governance gap between itself and the GPs in the LSHU. Tensions with the GPs had arisen as a result of an evaluation system that had been imposed on the GPs in the 1980s. According to this system of so-called ‘good practice pharmaceutical expenditure’, the 10 most-frequent prescribers were called upon to explain their prescribing habits. This practice was referred to by GPs as ‘an inquisition’. One manager commented in the present study that mutual mistrust remained, and that it ‘flaps like a ghost’.
From 1994 onwards, regional politicians began to apply pressure to balance budgets, which, from the GPs' perspective, impinged upon their jurisdiction. The LSHU's medical director, who had practised as a GP, played an important role in engaging and communicating with GPs. As one management respondent commented in the present study:
The medical director was a former colleague who could understand the GPs; in some ways she could justify them, protect them and help them.
As a result, dialogue switched from budgets to quality of service, as reflected in the following comment from a GP:
The organisation … always said: ‘We don't speak about expenditure’ – although it, like any organisation, always has its budget at heart. However they posed it in a different way: ‘If the work we do is good and a GP happens to spend more, that's fine’. But, although this was their official position, the organisation's real interest was saving, without doubt!
Only a minority of GPs supported the introduction of management accounting at this time. Dialogue was therefore instituted with this group on the subject of service quality. This dialogue encouraged GPs to adopt a wider understanding of the concept of ‘quality of service’ – that is, to look beyond the individual patient to the societal context of resource distribution. This was in accordance with the World Medical Association's (2005) view of ethics, which had shifted from the perspective of caring for a single patient to embrace a wider societal perspective. 21 It also took into account emerging views on the nature of health care. 22,23 By 1996, this informal dialogue had been formalized with the formation of a pilot group meeting, held twice weekly, involving the CEO, the social director, the medical director, the administrative director, three district directors and nine GPs, some of whom were members of GP professional associations. According to documents, the aim of the pilot group was to propose a ‘shared and feasible’ budget allocation for each GP, based upon ‘equity’ and objective criteria. Moreover, the pilot group aimed to base the health-care system on the doctor–patient relationship, rather than on a doctor–illness model. The issues of ‘quality’, ‘transparency’ and ‘integration’ were also emphasized in the documentation that established the pilot group.
Potential tensions with regard to budgets and changes in accounting systems were thus avoided by focusing on service quality and an acceptable ethical framework. Indeed, dialogue regarding equity of access and service quality led the group to begin speaking of the concept of an ‘ethical budget’. This reflected the importance attached to ethical considerations (such as resource distribution) by GPs. These Italian developments were in general accord with the notion of an ‘equity group’, which occurred in England in the mid-1990s when a group of GPs met to identify a formula for resource allocation for a district health authority. 22
The socialization process
Doctors in the pilot group were keen to examine the figures on patient care that were provided by a data-processing unit that supported the group. In an endeavour to understand costings and the possibility of developing an ‘ethical budget’, the GPs began to develop a greater interest in accounting processes. The group investigated various types of costs (including hospital admissions, pharmaceutical expenditure and consultations) and their distribution in terms of age, gender, pathologies and means of payment (co-payments, invalid pensions and so on). 24 For the first time, doctors thus became aware of the LSHA's distribution of costs and how these related to epidemiological patterns.
To the surprise of many of the doctors, it became apparent that 85% of expenditure was spent on 15% of the population. Transparency regarding expenditure thus diminished the GPs' mistrust of statistical data; moreover, personal involvement began to engender commitment. 25 The GPs became ‘socialized’ in terms of accounting values as they began to understand the origins, significance and value of statistical data. As Ellwood 26 has shown, following such ‘socialization’ doctors can actually come to enjoy juggling with numbers.
Deeper analysis by the pilot group led the doctors to investigate individual pathologies and to examine various ‘care packages’ at the district level. Once the group had a shared understanding of costs and expenditure patterns, the doctors began to comment on resource utilization and to engage with budget tools to test alternatives.
District budget groups were established within each of the three districts to implement the work of the pilot group and to identify disparities in levels of care. This process included an investigation of differential levels of service quality between primary care and secondary care, thus initiating the engagement of hospital doctors with the wider cohort of GPs. One of the GPs commented on this development in the following terms:
For the first time I was at a table with the consultants. I felt, for the first time, that I was an equal … There was real dialogue, which was constructive.
The dialogue between GPs and hospital doctors focused on reducing waste and inefficiency with a view to improving services. For the first time, GPs were engaged with the wider health-care community in a constructive debate that led to greater recognition of GPs by hospital doctors in a range of related fields. The medical director commented:
GPs are acquainted with the social situation and clinical history of their patients and will therefore recognise the most suitable paths to follow.
By this time, GPs had become increasingly aware that management accounting could provide practical solutions to their resource concerns by reducing wastage. By 1997, management was able to convene a conference to present the pilot group's findings. a The theme of the conference was the transformation of the budget from being purely a financial tool to being also an ethical tool.
After the conference, some momentum was unfortunately lost when a new medical director was appointed. However, constructive activity continued in the pilot group and at the district level.
Formal agreements
In 1998, the LSHA introduced a budget that was designed to be (in the words of the accompanying documentation) ‘… an incentive fund for the development of the district activities’. GPs were invited to select from a menu of activities, each of which was linked to economic incentives. The LSHA decided to give half of the amount due at the start of the chosen project, with the second half being transferred to the GP at the expiration of the agreement (based on the evaluation of effort entailed and output produced). This strategy of providing incentive to GPs proved to be crucial. In the words of one GP:
From my point of view the incentive had a big impact … previously there wasn't a culture of doing this work. From my point of view, it is good to be paid, because the work takes time.
At the beginning of the 1999–2000 fiscal year, GPs were asked to sign a new contract, which stipulated: (i) involvement in ‘quality circles’; (ii) agreement to pursue stated objectives (such as caps on hospital admissions, specialist service referrals and pharmaceutical prescribing); (iii) participation in refresher meetings for GPs; and (iv) a detailed clinical report accompanying patients referred to hospitals. In addition, these new arrangements included the prospect of incentive payments.
The instigation of ‘quality circles’ was novel. For the first time GPs were asked to meet and discuss patient management. The objective was to enhance the quality of management and enhance information flows, but this was a radical departure for professionals who had previously operated independently of their peers in day-to-day working. Some GPs viewed the prospect of ‘quality circles’ with trepidation. In the words of one GP:
It was a ‘black beast’ [that is, something to fear] … many doctors were worried by working together.
Like the early meetings of the project panel, the ‘quality circles’ initially focused upon improving service quality, rather than budgeting. It was hoped that shared standards and protocols might emerge as the ‘quality circles’ identified issues that were relevant to their own areas. To assist the work of these ‘quality circles’, all GPs received demographically segmented data on the hospital admissions, pharmaceutical utilization and consultations of their own patients during a specified period. In addition, GPs received quarterly reports in which the same information was benchmarked against the performance levels of their own ‘quality circle’, their district and the LSHA as a whole. All GPs received training in using these data, which reduced their scepticism – especially as the results were seen to change over time. Attitudes changed and many GPs began contacting the data-processing unit to ask about the data.
The new contractual agreement proved to be successful. Between 1997 and 2004, the number of patients requiring admission to hospital fell by 32%. In addition, although geographically isolated GPs had been allowed to sign the agreement as solo-doctor practices, the data began to show that the advent of GP networks (whereby doctors continue to work in solo practices, but that these solo practices are now increasingly linked together) had played a significant role in improving performance and changing styles of working. One doctor made the following observation about the advent of GP networks:
We derived some advantages, I do not deny it. I feel more relaxed … not only for holidays, but also in the event of need, I know that I can rely upon colleagues … But above all we tried to give something to the people… access to doctors from morning until evening.
By the time of the 2001–2002 LSHA budget agreement, more than 90% of GPs were working in GP networks (with 3–10 GPs in each network). By this time, the agreement stipulated: (i) a maximum two-hour response time to a patient call; (ii) longer weekday surgery opening hours; (iii) opening on Saturday mornings; and (iv) patient choice of any GP within a given GP network.
Reflecting on the advent of GP networks, one GP, who had not been a member of the pilot group, noted:
We have seen our clinic's health-care expenditure, which was already low, decrease even further. And the number of patients admitted to hospital has decreased dramatically. And, although we did not initially realise it, the small ideas that we exchanged were very important in achieving these results.
The same GP also commented upon changing attitudes:
It was initially disturbing for those who had always worked independently, and had never taken part in innovations such as this. However, attitudes began to change when doctors heard that one colleague is doing this and another colleague is doing that. In fact, I have seen several suggestions that I thought would be opposed, but everyone agreed.
It is thus apparent that doctors (perhaps unexpectedly) changed their attitudes.
The 2004 contract introduced a major change in the incentive system. This was targeted at GP networks, rather than individual GPs. This agreement made it compulsory for GPs to be in a GP network, with few exceptions (such as GPs who had their clinics in outlying areas). It also included new objectives, such as generating data for analysis. However, dispute over the new objectives caused some delay in gaining agreement for the new contractual arrangements.
A new attitude
It is apparent from the present study that GPs have now accepted the concept of budgeting. The following comment from a GP is typical:
We now have to send patients to the hospital with a full clinical report. This reflects well on the doctor's professional care and knowledge. But it also improves the likelihood of containing the organisation's expenditure as well. If a patient enters hospital with all the required diagnostic data, he or she will need less time in the hospital for tests. Depending on need, the care of most patients will thus cost much less.
GPs now perceive themselves to be part of a health-care system, rather than being independent contractors. This changed perception of their role has significant economic implications in terms of impact analysis.
27,28
The concept of budget is now accepted as part of a new framework of medical ethics in which cost awareness plays a legitimate role. As one GP observed:
The budget gives me the opportunity to keep working as I did before, but with more focus on what I am doing and whether I can do it better. The budget is not just about spending. The budget makes me more conscious of what I am doing… I have become aware of resource issues that I did not consider previously.
There has clearly been a move from an individualistic conception of the patient's interests to a societal perspective of medical ethics. As one managerial respondent noted:
The budget has enabled a better use of resources, improved quality, and greater equity in providing health-care services to the population.
Commenting on the doctor's acceptance of the economic dimension, a GP respondent observed:
Doctors had always been excluded from financial and economic discussions. But now economic considerations play a fundamental role in our work … doctors realise that the resources are not endless … There can be ethical problems … it is important that the patient is fine. However, the reality is that economic issues must affect a doctor's judgement … If there are no resources, how can I care for my patients? I have to make some choices. I have to follow some guidelines.
It is apparent that GPs had previously been approached inappropriately; indeed, in the past, there had been a tendency to impose new economic and accounting procedures, as was the case in the UK experience. 6
However, some GPs were reluctant to articulate their endorsement of this shift from an ‘individualistic ethic’ to a ‘societal ethic’. As one GP observed:
When you speak with your medical colleagues, you cannot say these things.
It was also apparent that some GPs complied with the new arrangements, although they did not really acknowledge that there were any financial problems.
The data provided in Table 1 summarize the effects of the changes studied here. From 1997 to 2004 the number of hospital admissions (expressed per thousand residents) decreased by 32%. This represents a considerable budgetary saving, which enabled more patients to be treated within primary care without the need for hospitalization.
Hospital admissions, specialty care and drug expenditure (1997–2004)
Source: Azienda USSL 4 ‘Alto Vicentino’
Outpatient specialist consultations increased from 10.3 visits per resident to 11.1 visits per resident, representing an increase of 8%. This percentage change was considerably less than the decrease in hospital admissions (32%).
These data also demonstrate that GPs had managed to change their prescribing behaviour. The data in Table 1 show that, compared with the regional average for drug expenditure per unit (excluding hospital drug expenditure), the investigated organization was 6.82% below average in 1997 and a remarkable 18.37% below average in 2004. It is evident that the GPs under consideration have adopted new prescribing patterns that are significantly more economical than those adopted in other regional organizations.
Discussion and conclusions
This case study has described how significant organizational change in a health-care setting can be achieved and how this change can result in financial sustainability and improved service. To achieve this organizational change, a group of professionals engaged with management and the wider organization, despite the opposition of other GPs who were sceptical of the proposed changes. The study has revealed how previously independent GPs shifted to a collaborative working model within an ethical framework that moved from a focus on individualized patient treatment to a wider societal perspective. In financial terms, the GPs shifted from having no budgetary responsibility to integrating performance indicators into their practice; in effect, the role of the GPs was transformed from that of gatekeepers of the system to responsible co-owners of it. The GPs altered their understanding of the Italian health-care system from an unrealistic perception of unlimited resources to a realistic appreciation of the need for an efficient distribution of scarce resources.
The change process reported in the present Italian study has many similarities with those previously described in the UK and New Zealand health-care systems. 10,29 However, in the present case, the changes went beyond new contractual arrangements and ‘top-down’ management innovations to include significant cultural change and intra-organizational integration. This required an evolutionary and non-linear change process. Doctors traditionally defend their professional autonomy against management-imposed change. 30–33 In the present case, the initial attempts by management to control pharmaceutical budgets were resisted; indeed, they were perceived as an ‘inquisition’. Nevertheless, by 2000–2001 the overwhelming majority (90%) of GPs had willingly agreed to work in GP networks and to accept performance targets. The Italian change process was thus more successful (albeit more prolonged) than other change processes – such as the Swedish nurse experience, which provoked significant opposition. 17
The most significant difference between the Italian experience and less successful attempts to induce change was the development of the concept of an ‘ethical budget’ as a change driver. This concept was based on a ‘higher principle’ that was readily accepted as being in accordance with the essential ethics of the medical profession. 4 In addition, GPs were initially asked to analyse and improve the quality of care for the patient; this was again in accordance with the basic values of the medical profession. In pursuit of improved quality, the doctors were actively involved in a study of service usage, and this highlighted the need for equity in service provision and resource allocation. In the context of limited resources, the budget was the natural tool to achieve improved quality and equity. However, because it was important that this management tool be detached from its reputation as being merely a means of imposed economic control, the organization wisely conceived the new label of an ‘ethical budget’. As a result, the Italian GPs came to view the budget, and the accompanying organizational change, as enhancing their professionalism by improving their care of their patients through the prudent utilization of available resources.
The organization also recognized that the ‘stratification’ of professional groups could be utilized to induce change. 34 The LSHA management therefore engaged GPs in a pilot group and encouraged them to engage in evidence-based dialogue on the question of access to quality care. Such communicative discourse has been previously shown to be effective in engaging professionals in change processes. 33,35,36 Once the GPs in the pilot group accepted that modern medical ethics require quality care to be placed firmly within a resource context, 21,28 they disseminated these ideas to their colleagues via informal discussion groups at a district level. The GPs thus adopted management's view of the imperative of scarce resources, and then reinterpreted this imperative in the language and value system of the medical profession. 27 This was in accordance with the Freidson's contention that peer-referencing is critical to such change processes. 37 By framing the imperative in terms of an ethical budget, the proposed new accounting discipline was no longer perceived as threatening.
A significant factor in the success of this discourse among medical peers was management's provision of data on care patterns and comparative costs. These data were aggregated at four levels (doctor, clinic, district and LSHA), which enabled GPs to take ‘ownership’ of it and internalize this new knowledge into their broadening perspective of the nature of health care. The accounting techniques of managed care thus evolved from being perceived as an imposition to being perceived as a novel development that GPs had shaped themselves. Such an evolution would have been highly unlikely without the initial enrolment of some professional advocates of change. The process took 10 years, but the professional advocates eventually grew from a small minority to become an overwhelming majority within the medical workforce.
The phasing-in of incentives enhanced mutual trust between the GPs and LSHA management because the establishment of shared values preceded the offering of agreed incentives. This can be contrasted with the experience in the UK, where fund-holder GPs have been accused of self-interest. 29,38 Although incentives played a significant role in the Italian case, the ‘ethical budget’ was structured in a manner that channelled slack resources into managed patient care. This meant that individual GPs could not benefit financially; nor could some GPs benefit at the expense of others. A non-recurring incentive was chosen to catalyse initial change, which was then embedded into systems without further financial incentives. In this case, the association of GPs in multi-doctor practices actually facilitated change. The GPs in the present study achieved a new collective identity that enabled them to insist upon an incentive arrangement that reinvested savings into managed patient care.
Freidson 39 predicted that rationalization and formalization would become drivers of change in health-care systems. It is arguable that these drivers were apparent in management's initiation of the change processes studied here. However, management's initial attempt at change (before 1992) was a conspicuous failure. In its subsequent (successful) attempts to produce change, management perceived that the GPs had the capacity to internalize rationalization and formalization by subsuming management accounting techniques within an ethical value system that acknowledged the validity of rationing scarce resources.
Previous research has noted the problematic nature of ‘top-down’ changes in accounting systems. 11,13,15 The Italian case confirms this. The study has demonstrated that change is more likely to be achieved through a mutual shaping and reinterpretation of proposed accounting reforms. It is apparent that it is possible to introduce management accounting among a population that has been badly affected by past accounting experiences. The medical professionals in the present study had little difficulty in understanding, reshaping and utilizing modern management accounting techniques to the advantage of patients – because they were enabled to posit the proposed changes within their own professional ethical framework. In this regard, the development of new organizational forms enhanced collegiate learning to the benefit of all.
In conclusion, the study affirms that management accounting is potentially useful and accessible to the medical profession. However, this requires careful alignment between the management imperative and the ethical framework in which doctors practise their profession. The concept of an ‘ethical budget’ has been shown to be an innovative and effective tool in achieving this alignment.
Footnotes
a
National conference held on 31 May 1997: ‘Il budget per medico di medicina generale e per distretto socio-sanitario da strumento economico a strumento etico. L'esperienza dell'ULSS n. 4 Alto Vicentino’ [The budget for the general practitioner and the social-healthcare district, from a managerial to an ethical tool. The LSHU n. 4 Alto Vicentino experience].