قابلیت حسابداری در برابر مشروعیت: یک مطالعه مقایسه ای با استفاده از اطلاعات حسابداری در بخش مراقبت های ویژه

This is a comparative study of management accounting in intensive care units in the UK and Finland. The management accounting problems of health care in many countries are well documented in the literature (difficulties of budgetary implementation: non-integration of health care professionals into the financial management process). This study examines these issues in the situation of intensive care, where there are difficult ethical decisions to be made by health care professionals in a climate of rapid medical advance where financial constraints may lead to rationing of health care. This paper reveals commonalities between these two countries in terms of intensive care problems, but there are differences, too, which can be attributed to contrasts in management accounting practices in the two countries.

Management accounting in health care has been the subject of a sustained research effort over the past couple of decades.1 This particular study builds on earlier research but also extends this by undertaking a comparative, international study of accounting practice in Finland and the UK to yield fresh insights into management accounting for health care. This study reaffirms the perspective that much is to be gained in explaining and understanding management accounting practices by undertaking studies of this comparative nature, and by relating local phenomena to global trends (Hopwood, 1999). The global trend affecting health care is the international pursuit of ideas of New Public Management (NPM), in which accounting has been given a central role (Hood, 1995 and Olson et al., 1998). The local phenomena are distinctive interpretations of, and practices of, management accounting in the same part of health care, in this case, intensive care. Management accountants and clinicians draw on different knowledge bases and so bring different perspectives to the issue of costs and rationing in intensive care units. This divergence is accentuated by the different social and institutional contexts of these study settings in Finland and in the UK, which emphasises the need for field studies to investigate comparative management accounting practice (Whitley, 1999). This paper is organised in five parts. First, the conceptual perspective adopted in this study is explored. This contrasts the tension between those studies of health care which depict accounting as a means of legitimating activities, particularly in the context of particular organisation structures, notably in the case of ‘decoupled’ or ‘loosely-coupled’ organisations, and the instrumental view of accounting in organisations. This instrumental view of accounting in action, labelled ‘accountingization’ (Power and Laughlin, 1992) has a functional understanding of the role of accounting. Second, the research context of this study is explored: the global phenomenon of NPM and its potential importance in intensive care. There are two strands to this: (a) a comparison of the manner and timing of public sector reforms in Finland and the UK and (b) management accounting and the specific part of health care which is the focus of this study—intensive care. These ideas are explored by a qualitative, interpretative investigation of management accounting in intensive care in four case study settings. This research method is set out in the third part of this paper. In the fourth part, the results of the investigation at the case study sites are analysed. This analysis extends our understanding of the kinds of phenomena which can be explained by these contrasting conceptual perspectives on management accounting and its role in organisation life. Finally, in the conclusion, we draw together the analysis of the comparative studies and offer a continuing research agenda.

Previous research on public sector organisations has concluded that there can exist or emerge a decoupling of service delivery by professionals such as doctors and managerial activity (Meyer and Scott, 1992, Scott and Meyer, 1994 and Weick, 1976). Our findings confirm this decoupling and suggest that it may be reinforced by the workings of the clinical team in the ICU, where the nature of the work and the interdependence of team members makes the ICU team a strong entity. There were further commonalities within these case studies of intensive care in Finland and the UK. The nature of the process of care (essentially demand-led and being responsive to emergency work, with a strong clinical team orientation) was the same, the kinds of non-financial information gathered routinely (TISS scores,3 APACHE scores) to assist in planning for these units were the same. However, the significant divergence between these two countries was in the role of management accounting information. The absence of an established management accounting profession and the willingness of health care professionals in Finland to assume the accountant’s role was accompanied by their commitment to financial targets, and a willingness to accept financial responsibilities. The development of “clinician-management-accountants”, in the Finnish context, and the strict resource limits set on the clinicians with administrative responsibilities, resulted in a penetration of medical professional activity by accounting ideas and practices. There were a number of aspects to this. Notable elements were the use of language, in which the expression ‘profit areas’ was used in discussing parts of operational health care activity. This implies a ready acceptance of accounting concepts and practices. Further facets of this included the centrality of the budget and the manner of its use. For example, there was not only a readiness to recognise physicians’ responsibility for hospital targets, but there was also a recognition that the chief physician (overall budget holder), in concert with ward sisters, “pulled all the strings”, i.e. not only managed the budget, but were integral to its calculation and construction. Indeed, there is even the observation of one ward sister (at Jonsson hospital) that the delegation of the ICUs own budget was “a dream”. Allied to this, there is the position of clinicians (“we have come to our senses”) on rationing care, and their greater willingness to act on calculation in determining their plans and priorities. This contrasts with the UK experiences, in which the dominant health care professionals, the doctors, continue to have primacy in the hospital. This dominance is strengthened by their mobilising of such accounting information and personnel as required to further their position. This situation we depict as accounting as a legitimating function, in which accounting facts, figures and arguments are assembled to project a defensive shield over the activities of the core—the health care professionals. As the clinical imperative was the impetus for spending, the role of the management accountant—characterised in this study as “the management accountant as historian”—was to make sense of budgets after the event, rather than to use accounting information to plan activity. In this way, budget outturns which exceeded allocations made could be presented to the hierarchy within the institution as necessary expenditure. Instead of the management accountant cast in the role of cost controller, as a negative influence, castigating those who overspend, here, the management accountant was a defender of clinical practice. Accounting expertise, and the management accountant, was the conduit by which the clinicians in this area presented their case of “need”. In this way, the existence of a distinct body—management accountants—does not threaten, does not permeate, but preserves the best of clinical practice in situations of tight financial resources. In Finland, management accounting is absorbed by health care professionals: in the UK, this accounting expertise is deployed as a defensive shield by health care professionals. The differing social and institutional contexts of management accounting practice shape its role as accountingization (“clinician-management-accountants”) or legitimating (“the accountant as historian”). These findings have important implications for future research in management accounting in health care. First, this research suggests that further, valuable insights into management accounting in health care might be gained by shifting the focus of research from the generality of health care to specific parts of health care activity. Second, this particular research underlines the need to reexamine what are portrayed as global trends in the context of local situations. Also this research points to the richness of studies of management accounting practice which are comparative in nature, particularly in different international settings. This paper drew on two, contrasting, theoretical constructs: accountingization and legitimation. These represent competing explanations of change in public sector organisations. Accountingization (Power and Laughlin, 1992) contends that accounting information has assumed a new (negative) significance in shaping the activities of public sector organisations. With accountingization, accounting information, practices and procedures penetrate deeply into the core of organisations, defining ‘what is’ and ‘what is not’: a device for controlling the constituent parts of the organisation. The theoretical construct of ‘accountingization’ can be seen as an explanation of what is generally regarded as NPM (Hood, 1995, 1991) in practice. The evidence of this research is that ‘accountingization’ can and does occur, but its emergence is contingent upon a number of factors: first pressures from the external environment must exist which promote a greater visibility for, and action on, accounting information. However, this alone is not sufficient to bring about accountingization. In the social context of Finland and the UK there are commonalities (‘Results Management’ in Finland and general management in the UK: the implementation of quasi-markets in the UK and Finland), but these do not explain the phenomenon of accountingization. A second factor which is crucial to the emergence of accountingization is the manner of implementation. Reference has been made in the paper above to the ‘hectic and harsh’ (Pollitt and Bouckaert, 2000) UK implementation of reforms which contrasts with the lengthy trajectory of the reforms in Finland. In dealing with complex, sensitive situations, the lengthy Finnish trajectory looks to be most successful. However, while both the wider context and the manner of implementation are significant these factors are not sufficient to allow accountingization to take hold. A further factor is the receptivity of the specific setting, as measured by the presence or absence of professional or institutional barriers or constraints. The absence of a well established management accounting profession present as a point of entry for accounting ideas (given factors 1 and 2 above) to transfer across, and become embedded in the core of the organisation, which is represented by the health care professionals in this study. The above analysis cannot be taken as an advocacy of the universal applicability of NPM (‘acountingization’) across all settings. However, the competing theoretical construct of legitimation also has explanatory power according to the evidence in this paper. With legitimation actions and decisions, and internal structures may be decoupled to present a symbolic picture of how organisations are constituted, such that the core (in this case the health care professionals) are buffered from the external environment. The external environment is a crucial element in the emergence of legitimating behaviour and this reflects the accountingization experience of this study. However, this is not sufficient to ensure there is legitimating behaviour within public sector organisations. Where there is significant grouping of expert professionals (accountants in this case) alongside the dominant professional cadre (the health care professionals), there is potential for discourse or conflict. Where such conflicts raise issues at the very core of the organisations (such as life or death decisions over admission to, or continued treatment in intensive care units) the core values will be dominant. In this situation, the subjectivity and malleability of accounting constructs (the situation of overlapping budgets, the ‘management accountant as historian’) enables accounting to be deployed as a legitimating device in the pursuit of the aims, objectives and interests of the core of the organisation. Therefore, to conclude, this research suggests multiple paradigms (here: acountingization and legitimation) offers a rich framework for the further investigation of management accounting and control practices in public sector organisations, such as hospitals.