6 Enterprise, hybrid professionalism and the public sector

Mirko Noordegraaf

Introduction

The public sector is highly dependent upon professions, professionals and professional work. Medical doctors, nurses, police, public persecutors, judges, teachers, social workers – they all provide essential public services, which implies treating individual cases (such as patients, pupils or criminals) in the light of public objectives and formalised policy programmes. Public professionals, in other words, treat cases in order to serve generic public or societal ambitions – such as public health and safety – as well as more specific policy programmes that have been formally agreed upon in order to realise such ambitions.

In that sense, public professionalism was never ‘pure’ (Noordegraaf 2007). Public professionals feel the dependencies and were never ‘free’ and autonomous. Public sectors are dependent upon professionals, and professionals are embedded within public sector regimes. Their leeway was always constrained and will always be constrained, by policy ambitions and regulations, as well as bureaucratic parameters and requirements. Since the 1980s, however, these constraints have intensified. In the ‘era of enterprise’ public professionals have been immersed – many would say ‘captured’ – by neo-liberal regimes, managerial ideologies and well-organised sets of instruments that belong to the so-called ‘New Public Management’ (see, for instance, Enteman 1993; Hood 1991; Pollitt and Bouckaert 2004). Their purity has therefore further eroded. In addition to constraints that come from policy and bureaucratic surroundings, they face managerial and organisational constraints, with strong businesslike, consumer and market overtones. Professional services not only have to implement substantive objectives like fairness, equity and accessibility and procedural goals like legality and uniformity. They also have to perform, establish outputs and outcomes, and account for their actions. They have to be managed and organised, with a stress on efficient, effective, innovative and customer-focused action.

This has generated widespread and much-debated conflicts between a professional logic on the one hand, and bureaucratic and organisational logics on the other (see, for example, Hood 1991; Noordegraaf 2015; Reay and Hinings, 2009). It has also generated analyses of how public services and professionals respond to, and deal with, such conflicts. There are three ideal typical responses. First, conflicting logics remain separate and a separate professional logic is maintained and protected. Second, the logics interact and can be combined so that professionals can act and organisations can perform. Third, the logics are interwoven and professionalism becomes hybrid, so that professionals start to perform in new ways. In this chapter, these responses will be elaborated, in order to assess the state of professional services in the public sector in the era of enterprise. The third response – professional action as a hybrid phenomenon – will be especially accentuated, as it represents the most realistic and hopeful response. Entrepreneurial realities cannot be taken away, and well-organised action might enhance instead of harm the quality of services. This, in turn, needs a thorough understanding of what ‘well-organised’ means. We will argue that this is a matter of organising, much more than of ‘organisations’, let alone ‘corporate’ organisations that act in ‘businesslike’ and ‘entrepreneurial’ ways. This enables us to go beyond hybrid professionalism and portray public professionals as agents who do not merely treat cases, but who co-organise service provision, in order to be more effective and innovative, both for (multiple) cases as well as society at large. We will argue that public service enterprises find ways to enhance collective professional action which serves multiple instead of singular performance criteria.

Conflicting logics

A few professions are strong professions, representing classic or ‘pure’ professionalism (Noordegraaf 2007) – such as medical doctors, lawyers, accountants and engineers (see, for instance, Krause 1996; Larson 1977; Reed 1992). They have managed to establish strong associations and regulative mechanisms, backed by the state and universities (Burrage and Torstendahl 1990; Muzio et al. 2011) that enable them to regulate their own occupational fields and practices. This means they have institutionalised autonomies and much discretion as well as independence when they treat cases. Other professions might strive towards this ideal typical – and ideal – conception of occupational self-control, but they have not really attained this. They are part of ‘weaker’ professional fields, with less forceful regulative mechanisms, and they face many external demands and constraints – such as nurses, teachers, police officers and social workers. But even judges, who are seen as ‘strong’ professionals, are more embedded professionals than medical doctors, as they are part of the legal systems and law courts, which have to secure certain legal, programmatic and bureaucratic standards that do not really come from within professional fields. Obviously, medical doctors must respect the law, follow rules, and can be held accountable, but many rules and regulations come ‘from within’. These other professions face rules and regulations that come from ‘the outside’.

Many of these professionals are public professionals, or public professional workers. This is understandable, as public professionals might be part of professional fields, but they are also tied to political and policy programs, as well as bureaucratic systems. According to authors like Clarke and Newman (1997) they are part of ‘bureau-professional regimes’. They have to contribute to higher-order societal objectives, such as public health and safety, and they have to implement formal policies, such as health care, educational and safety policies, and they have to follow procedural standards, in order to guarantee uniform, reliable and legal (client) treatment. Even pure professionals who have become part of public systems – such as medical doctors in publicly organised and funded health care systems – face such demands and constraints, and their purity is reduced.

These programmatic and especially policy standards as well as bureaucratic constraints are rather traditional, and they have become more important with the rise and extension of welfare states. In the 1980s this started to change. Welfare states were ‘restructured’ (Klenk and Pavolini 2015). With the rise of neo-liberalism in countries like the United States and the United Kingdom (but also many other Western countries), the era of enterprise entered public domains. The ‘market’, ‘corporations’ and ‘entrepreneurship’ became crucial images for organising public sectors, and the New Public Management offered new businesslike tools for running public organisations (see Clarke and Newman 1997; Hood 1991; Noordegraaf 2015; Pollitt and Bouckaert 2004). More practically this implied a stress on measurable results and outputs, economic yardsticks (economy, efficiency and effectiveness), transparency, innovation, customer focus, and clear lines of accountability. At first sight, new organisational and managerial models and regimes started to replace programmatic and bureaucratic regimes, aimed at optimising such a performance logic (Noordegraaf 2015). Public organisations and even sectors were designed as if they were corporations, with strategic apexes, production units or divisions, and output standardisation (Mintzberg 1983). Public executives and managers started to work along the lines of planning and control cycles with much stress on ‘plan, do, check, act’ (PDCA). They started to use monitoring systems, quality control and customer satisfaction ratings, with lots of emphasis on clear facts and figures, or ‘management by measurement’ (Noordegraaf and Abma 2003). They started to unleash ‘entrepreneurial spirits’ (Osborne and Gaebler 1992).

This new logic, a performance logic – alternatively called businesslike logic, organisational logic, managerial logic, entrepreneurial logic, commercial logic – put much pressure upon a professional logic, as the main thrust of performing more effectively runs against the main thrust of acting professionally (see, for example, Exworthy and Halford 1999; Noordegraaf 2015; O’Reilly and Reed 2011; Waring and Currie 2009). Instead of quality, a performance logic puts much stress on quantity. Instead of autonomy, much stress is put upon control. Instead of tacit knowledge and expertise, much stress is put upon codified information, and so on. But things are actually even more complicated, as more traditional programmatic and bureaucratic regimes have not dissolved. Professional action is not only influenced or captured by organisational and managerial regimes, but also by policy programmes and bureaucratic standards. These regimes have become bureau-managerial-professional regimes. Conflicts and clashes between (multiple) logics are no surprise – in fact, they are to be expected. Conflicts are part of the performance logic itself, for example as corporate optimisation clashes with entrepreneurial innovation (see, for instance, Hood 1991), but more importantly, the performance logic clashes with complex professional work in contested policy environments.

Many authors have underscored the importance of these conflicts, at various levels. Some authors have stressed conflicts at the level of public/private values (as illustrated by Hood 1991), ideologies (as exemplified by Clarke and Newman 1997; Evetts 2003; Jacobs 1992) and identities (as indicated by Thomas and Davies 2005). Others have stressed conflict at the level of institutionalised practices in systems that are both businesslike and professional (such as Reay and Hinings 2009) as well as organisational actions that represent different institutional logics (for example, Becharov and Smith 2014; Skelcher and Smith 2015). Some authors have stressed conflict at the level of professional work and actions in businesslike environments (for instance, Numerato, Salvatore and Fattore 2012; Waring and Currie 2009) and professional motivation that is weakened by businesslike pressures (for example, Tummers 2013; van Loon 2016). Irrespective of how we see and value the rise of an era of enterprise, we have entered a conflict-ridden era which calls for appropriate political, organisational and professional responses.

Responses to conflicting logics

Although conflicts are unavoidable, almost ‘objectively’ given and certainly subjectively experienced, we must be careful not to exaggerate the presence and effects of conflicts. First of all, conflicts might occur with less or more intensity, depending on broader circumstances. The New Public Management, for example, has affected different countries in different ways (Pollitt and Bouckaert 2004). In some countries, especially Anglo-Saxon countries, the New Public Management has been implemented in strong and sometimes radical ways. In continental European countries, this has taken on much more moderate forms, with the Netherlands and Nordic countries in-between Anglo-Saxon countries and France, Germany, and other Southern and Eastern countries.

Second, conflicts might be productive, that is, an emphasis upon results and transparency is not a bad thing in itself. Public policies and services might be improved, when performance pressures are exerted. An emphasis on more tangible results or more efficiency, for instance, is not bad as such. Not wasting public money or improving ‘delivery’ might also be valuable from a public or societal point of view. Whether conflicts are productive depends partly on the circumstances. In settings with less ambiguity and contestation, it is easier to focus on outputs and outcomes. This is especially so when there is lots of technical and ethical contestation – when ideas, interests and emotions clash, it is difficult to work with strict performance systems (Hofstede 1981; Hoppe 2011; Noordegraaf 2015; Noordegraaf and Abma 2003). For example, when medical interventions are new or highly complex, or when they are ethically contested, or when policing methods to trace drug trafficking or cybercrime are far-reaching, it is logical that strictly managing performances is of limited value. In addition, whether conflicts are productive also partly depends upon how they are managed. Even in ambiguous or contested circumstances, interventions might be made transparent and measured, but only productively when managers do this in smart and subtle ways – when they keep performance measurements active and lively, when they limit (financial) consequences and sanctions, and when they turn performance management into an interactive and dialogical affair (as illustrated by De Bruijn 2007; Moynihan 2008).

Third, conflicts can be dealt with, and not only by managers. Even when conflicts are intense and not automatically productive, people who are affected by them – including professionals – have the means and ways to cope. In other words, not only managers but also public professionals and other staff members might have the capacity to respond to conflicts. They might work against or with pressures and make sure that ‘good’ things happen, due to or despite ‘bad’ influences. Professionals and others are not only passive victims, but (re)active agents as well. When they work against pressures, they try to defend their autonomies and ways of working, something that is often emphasised in the analysis of professionals’ responses when they show passive or active resistance (for example, Thomas and Davies 2005; Tummers 2013; Waring and Currie 2009). When they work with pressures, they might comply and conform, or do ‘something’ with performance pressures in order to improve their work, while maintaining their sense of professionalism (as illustrated by Reay and Hinings 2009). Especially when professionals are able to deal with multiple (and conflicting) demands and expectations in positive ways, by performing professionally in political contexts, we see the rise of what we call ‘professional capability’ (see van Loon et al. 2016). Instead of merely protecting professional autonomies or combining professional and managerial logics, more hybridised responses are deployed. New forms of professionalism are ‘enacted’, also by professionals themselves, instead of ‘demanded’ (Evans 2011).

Multiple ways of responding to conflicting logics

Many of the authors who have discussed conflicts have examined coping responses, and many other authors investigate how professionals actually deal with pressures. These responses might have multiple consequences:

How conflicts are dealt with, with what specific effects, is variable, however, and are far from clear in an empirical sense. In other words, we have to identify multiple types of responses, especially when we study professionals. This means we need to refine the ‘working against or with pressures’ line of thought. When we survey the literature on coping with conflicting logics (the literature we just mentioned, as well as Martin et al. 2015; Numerato, Salvatore and Fattore 2012; Oliver 1991), we see the various types of responses to which we have already hinted. In addition to (1) merely protecting professionalism; (2) professional and organisational/managerial logics might also be combined; or (3) these logics might be interwoven so that more hybrid forms of action are enacted. These three major ways of responding to conflicts, especially by public professionals, are summarised in Table 6.1 and are briefly discussed beneath it.

Protecting a professional logic

First, professionals might protect their professional logic, including identities and autonomies, and external pressures might be resisted, countered and kept at a distance. A performance logic is seen and experienced, but it is viewed as problematic and counterproductive. Much effort is put in reducing the effects of the New Public Management. This might be done by working against New Public Management and opposing its instruments, covertly or overtly, or it might be done by working along with New Public Management impulses, in order to neutralise their effects, or even to use it against managers (see, for example, Waring and Currie 2009). Responding to performance pressures in order to reduce effects might – all in all – vary from:

Apart from these modalities which can be traced empirically, there is a clear normative thrust in many contributions to this debate. Freidson (2001) for example tried to rescue a professional logic – the ‘third logic’ – from omnipresent managerial and consumer logics. Professional and organisational/market/ entrepreneurial actions should remain separate, and organisational/entrepreneurial action should be reduced as much as possible in the case of services like health care, welfare, safety and education. At most, organisational and managerial actions are ‘custodial’ (Ackroyd, Hughes and Soothill 1989), that is aimed at guarding professional leeway and discretion. This is not only academically stressed. In fact, a large part of recent political and public discourses is fuelled by comparable normative sentiments, both in a very general sense of ‘rescuing the public professional sphere’ (see, for instance, Jansen, van den Brink and Kole 2010) and in a more specific sense, with an eye on specific sectors such as health care or education (for example, Evers and Kneyber 2015).

Combining professional and organisational logics

Second, professional work might become part of combinations of logics, aimed at combining ‘best of both worlds’. Reay and Hinings (2009), for instance, have shown the importance of ‘pragmatic collaboration’ in the Canadian health care system. They showed how professional and organisational action could be related, without producing negative feelings and effects. They identified four mechanisms for improving results and keeping professionals satisfied: (a) linking medical professionals to decision-making; (b) using medical professionals’ expertise; (c) seeking outside enemies (the government); and (d) creating room for experimentation and innovation. De Bruijn (2002), to take another example, identified various options for managing and measuring performances along the lines of a businesslike logic, but in such a way that ‘management by measurement’ (Noordegraaf and Abma 2003) becomes meaningful. As highlighted above, he stressed the importance of variety, of keeping performance management and measurement dynamic and lively, and of organising interactions, so that measurement outcomes can be interpreted. This is comparable to other elaborations of meaningful performance measurement. As others have also shown, performance measurement does not dissolve ambiguities; complex issues can be measured and interpreted in multiple ways; and we need dialogue to make sense of performance data (Radin 2006; Moynihan 2008). Instead of seeing measurement and evidence as ‘end points’ in improving organisational action, it is much more fruitful to use them as starting points for dialogue and debate (Noordegraaf 2008). These dialogues might not only include professionals, but also other stakeholders.

These insights are very practical and fundamental at the same time. When professional and organisational logics clash, public service organisations might establish day-to-day mechanisms for linking organisational and professional worlds, in such a way that organisational ambitions and targets are operationally translated into professional action, and vice versa. These translations, at the same time, are strategic in that they leave the logics, as such, untouched. They assume that there is a certain essence or ‘core’ of organisational and professional logics, which are both needed to secure well-organised action. This essence of professionalism should not so much be protected, but respected. At the same time, this implies that multiple logics remain distinct and separate, although they are connected. Authors assume that both organisational and professional logics have a core ‘essence’ that deserves this respect. In their analysis of how medical professionals respond to changes, Martin et al. (2015: 378) conclude: “In systems characterised by fissures between professional groups and powerful market and managerial influences, we suggest that professionalism must interact creatively but carefully with other logics”. This differs from the third type of response, in which distinctions between logics become much more fuzzy.

Interweaving professional and organisational logics

Third, and again differently, professionals might interrelate and interweave their logic with other logics, so that elements of logics are actually coming together in both organisational and professional practices. Professional identities and acts then embody multiplicity instead of singularity. This response has become well known in widespread debates on hybrid professionalism (for instance, Denis, Ferlie and van Gestel 2015; Noordegraaf 2007, 2015; Waring 2014; Skelcher and Smith 2015; Waring 2014). Instead of seeing professionalism as something distinct, separate and loose from other logics, with a distinctive core, both organisational and professional actions are seen as something that is/can be reconfigured. Values, identities, practical action or elements of other logics can become part of professional fields, outlooks and actions. This goes for both programmatic and bureaucratic as well as organisational and managerial logics. Professionals, for example, might still strive towards ‘free’ or autonomous case treatment, but also acknowledge the importance of policy guidelines and procedural justice when they treat cases, and acknowledge the importance of tangible outputs and client and/or stakeholder satisfaction when they treat one or multiple cases. This is called ‘hybrid’ because it might still feel unnatural, but at the same time it might be seen as a natural part of the job (Noordegraaf 2015).

When dealing with conflicting elements is seen as something natural, we might even go beyond hybridity, and trace forms of reconfigured professionalism in which multiplicity is actually preferred over singularity. Professionals might acknowledge the importance of treating multiple cases instead of one case; of dealing with multiple values, including economic ones, instead of one value such as ‘quality’; and of dealing with multiple realities, including political and societal realities, instead of one reality such as the professional–client interaction. This has implications for the coping capacities of professionals – we will turn to this later – but of course this concerns much more than ‘a’ professional or professionals. In the case of reconfigured professionalism, it is not so much ‘a’ professional or individual professionals that render services. It is teams of professionals, support staff, managers, clients and stakeholders who jointly produce services. Service processes become much more important than individual service professionals (Noordegraaf 2015). In health care, clinical guidelines, for example, might be ‘carriers of institutional change’, as Adler and Kwon (2013) have shown. Clinical guidelines might support the strengthening of professional collaboration, aimed at rendering ‘better’ services. ‘Better’ then means multiple things: client-focused, effective, innovative and efficient. Since this third type of response is the newest and the least developed, we now mainly highlight hybrid professionalism. Later, we again return to protected professionalism and pragmatic collaboration.

Hybrid professionalism

We think that the third response – interweaving logics and developing hybrid forms of professionalism – is especially important, for various reasons. First, it is realistic as many professionals and especially public professionals cannot stick to the ideal of pure professionalism. They face (too) many constraints, due to their public status and roles, due to the era of enterprise that requires demonstrable performance, and due to the broader transitions that public services are going through, driven by changing client preferences, new technologies, transnational standards, political shifts, social media, and so on, in domains like health care (for instance, Plochg, Klazinga and Starfield 2009), education (for example, Hargreaves 2000) and law (as illustrated by Faulconbridge and Muzio 2012). Moreover, there are many real-life examples of reconfigured public professionalism in which the elements of professional action change and become plural, in the light of changing context (see, among others, Noordegraaf et al. 2016).

Second, developing hybrid professionalism is optimistic, not only because it focuses on these real-life examples, but also because it offers more forceful ways of working towards more vital professional services. This is mainly the case as hybrid professionalism neither negates nor ignores conflict nor seeks to work against conflict, but makes sure that professionals themselves recognise conflict and are equipped to deal with it. Instead of working with or against ‘demanded professionalism’, they ‘enact’ professionalism, as Evans (2011) has argued. Conflicts are no longer located in-between different parts of the organisation (such as managers versus professionals, each carrying different logics), but they are located inside work flows, in which professionals and others make sure that ‘valuable’ services are rendered. What ‘valuable’ means is difficult to define and delineate, so the ones that are responsible for rendering services – including professionals – should acknowledge the complexity of this responsibility and find ways to cope with this. How this is, can and should be done, is explained beneath.

From professionals to professional work flows

‘A’ public professional, such as ‘a’ medical doctor or ‘a’ judge is and remains important. He or she does not so much treat cases, but embodies a higher cause and calling (see, for instance, Wilensky 1964). When he or she treats a case, something bigger is involved, symbolised by the appearance, rituals and physicality that surround case treatment. This is not only done to make decisions happen – it is also done to make decisions authoritative and to signify that certain higher values are at stake, such as ‘independence’. At the same time, ‘a’ professional is a relative thing, as services cannot be rendered by individual professionals. On the contrary, modern health care, judicial and educational services, especially, need multiple professionals and support staff to render services and to make sure that the conditions for rendering services are met, including conditions that are important to secure convincing external or public communication, to secure financial soundness, and to secure judicial back-up if necessary. All of these acts are important inservice environments that are (potentially) critical of the services rendered: politicians, journalists, clients and other stakeholders might emphasise ‘mistakes’ and ‘errors’ much more than normal and/or successful case treatment, and public services might get into trouble because of case-related communication, financial problems and judicial matters.

This implies first and foremost that the era of ‘autonomous professionals’ is over, as authors like Hargreaves (2000) stress, and that we have entered the era of ‘collegial professionalism’. Professionals have to collaborate and work together, in teams and networks. This is also stressed by others, such as Adler, Kwon and Heckscher (2008) who stress the rise of ‘collaborative communities’ in health care. In addition, it implies that work processes and work flows count, that is processes and flows in which teams of professionals, as well as support staff, managers and stakeholders work together to render sound services, at various levels (Noordegraaf 2015).

Case treatment

Professionals and other staff members work together in order to realise sound case treatment, that is case treatment that is valuable, timely, efficient and satisfactory. The more complex a case, the more important is inter- and multiprofessional action, including the mechanisms for realising this. One can think of multi-disciplinary meetings in health care aimed at bringing medical professionals together when a complex case – such as in oncology – is treated; or of multi-disciplinary networks for helping clients with chronic diseases in ways that cut across the clinical, ambulatory and private spheres. As indicated, formal instruments like clinical guidelines can facilitate this (as illustrated by Adler and Kwon 2013). They enable professionals and others to standardise medical action and secure quality, timeliness, innovation and efficiency.

This means that guidelines themselves have become ambiguous objects, aimed at tackling ambiguous situations. Instead of being produced by either medical professionals on the basis of medical reasoning, or by organisations or inspectorates in order to measure and account for actions, they are medical/ professional and organisational/managerial at the same time. Moreover, they embody multiple values: they serve the patient, both in terms of high-quality as well as speedy and timely treatment, they serve the interests of other patients, for instance, by saving time, and they serve organisational and political agendas, for example, by saving money. This also reinforces the ambiguities of ‘entrepreneurialism’ in the era of enterprise. Instead of either favouring or limiting entrepreneurial spirits, entrepreneurialism moves in different directions at the same time: medical technologies are improved, evidence-based medicine is strengthened, value-based care is propagated, client satisfaction is measured, and stakeholder expectations are taken into account – with all aimed at moving beyond strict separations between ‘cure, care, control and community’ (Mintzberg 2017).

Multiple case treatment

Traditionally, professionals mainly work on one case, and then the next. They put as much time and attention in this one case as possible. In the case of hybrid professionalism, this view is problematic. Professionals and other staff members increasingly work together on determining how to treat multiple cases, including how to prioritise cases, when to treat certain cases, and how to deal with delayed or backlog cases. The more cases flow towards a public service organisation, the more important this becomes. Professionals need shared mechanisms for making trade-offs, especially when the number and nature of cases, including the complexity of cases, exceed capacities. This brings us back to the concept of multiplicity. In terms of yardsticks it is increasingly difficult to define and assess medical professionalism, or any other form of public professionalism. Instead of mainly saying that ‘good’ medical action is serving ‘the’ interests of ‘the’ patient, it is much more realistic to say that ‘good’ medical action serves multiple interests of multiple patients, in wider political, technological and financial contexts. This all the more means that professional action in the era of enterprise is collegial action.

Treating (multiple) case treatment

Finally, concerning these wider contexts, professionals and others not only work together to determine how cases should be treated. They do so in wider and often critical environments that expect clarity, cost control, safety and lack of risks and errors. Professionals and others will have to be able to use mechanisms and skills for dealing with such critical forces, varying from political criticism via journalistic attention to citizen claims. This – among other things – implies that they have to be aware of the risks they generate, especially when they treat sensitive cases; to acknowledge the political and/or judicial implications of their decisions; to deal with public exposure; to use or withstand social media that make services transparent in new ways; and to reflect upon how they work and whether they possess the right competencies to ‘survive’ and remain healthy.

Given traditional images of professionals, it is attractive to limit joint professional action to the first level, and to leave the other two levels to ‘the organisation’ or ‘management’. From the perspective of reconfigured professionalism this is untenable. On the one hand, it reproduces the conflicts that are seen and experienced as burdensome. When a case is left to professionals, and multiple cases and contexts are left to organisations, conflicts between professionals and organisations will increase, as there are growing tensions between cases and between cases and contexts, especially when ‘a’ case is treated. When the treatment of a case absorbs much time (and money), other cases are negatively affected – and clients might go to journalists or lawyers about this. On the other hand, it ignores the fact that setting priorities and dealing with critical environments cannot be isolated form professional action – it is professionals who share responsibility for this, not least because they use financial, technological and organisational resources when they treat cases, and how they do this influences how many cases can be treated and whether stakeholders become active or remain silent. Trade-offs in other words are tied to their actions: the time and attention they spend on individual cases cannot be spent on other cases. Quality, then, is more than maximum or absolute ‘time’ or ‘space’; it is relative time and space: time spent on one case is relative to risks as well as to time spent on other cases.

Dealing with consequences

This situation has two major consequences. First, professionals will have to acknowledge that they are co-responsible for organising service processes. Organising case treatment, based upon the deployment of resources, is not detached from their work, but is their work. Second, professionals need to acquire new abilities, or more technically, competencies and capacities, in order to deal with more complex cases and service contexts. In the text below we will briefly explore these two implications.

Organising as part of work flows

Obviously, there are many instances when ‘a’ professional interacts with a client. When a general practitioner speaks with one of his or her patients, when a police officer deals with a burglary, when a lecturer supervises a Masters or PhD thesis, or when a judge treats a criminal offence, there is identifiable communication between a well-trained expert and someone who wants, needs or requires a public service. But even these instances cannot be separated from the work flows required to render such services. Appointments need to be made, case treatment needs to be prepared, additional investigations might need to take place, follow-up actions might be necessary, various things need to be registered, other professionals or experts might need to take another look, or might be needed to complement professional action, and so forth. The quality of services is therefore not merely tied to a distinct communicative moment, but to the chain of events. When the professionals mentioned deal with multiple cases, this only becomes more relevant. When the flows are organised smoothly, quality – including timeliness, speed and efficiency – can be assured, even when multiple cases compete for professional attention.

In many other instances, it is even more complex than this. In the case of more advanced surgery, or treating patients with multi-morbidity, or bigger criminal investigations, or running high-quality educational programs, the communicative moment, that is the bilateral interaction between professional and client, might still be crucial, but is rather marginal, when set against the bigger picture. Multiple professionals might be active, supported by colleagues and staff members, and how their interactions are co-ordinated and routinised influences the quality of services. Time and efficiency might even be crucial indicators of quality, for example when a speedy cancer diagnosis is made possible, or when law courts prevent delays and organise timely case treatment. This implies that time is relative. There might be time for professional–client interactions, to offer quality and mitigate risks, although this will have to be restricted, not least because other cases/clients also want time and attention. But the way in which these interactions are embedded within bigger work flows, in which professionals, staff members and organisational support are aligned in such a way that clients are treated or served timely and efficiently, also generates quality. This is not only an organisational matter that is, a matter for the organisation, but a matter of organising – of how crucial participants, including professionals, co-ordinate their actions and whether they have the skills and routines for co-ordinated action. Whereas organisations can be kept at a distance from professional action, organising is part of professional action. In the case of hybrid professionalism, these various spheres are connected (see Kirkpatrick and Noordegraaf 2015; Muzio and Kirkpatrick 2011). Ideally, organisations facilitate the ways in which professionals organise (multiple) case treatment.

Capabilities to cope with complexity

The latter remarks not only stress the importance of organisational capacity, but also of capability (for example, Noordegraaf and van Loon 2014) – especially professional capability. Traditionally, professionals are equipped, trained and socialised to deal with individual cases, and not so much for the things that are discussed above. Dealing with multiple cases, prioritising cases, dealing with time and money, working innovatively, stopping case treatment, making trade-offs in the light of scarce resources and financial constraints, keeping an eye on judicial and safety implications and so on – all of these more complex tasks and events are traditionally not seen as regular parts of professional repertoires. There are signs, however, that professional repertoires are reconfigured and that new attitudes and acts are developed, for instance by way of revised educational programmes that rely upon new competency models. A good example can be found in health care, where medical education is increasingly based upon competency models like the CANMeds model (Frank et al. 2010), stressing the importance of communication, collaboration, advocacy and day-to-day medical leadership.

The problem with competency models, however, is that they tend to focus on individual competencies instead of work situations in which (multiple) individuals will have to act and work together. This means that capacities are not so much individual but social and relational, and they need to focus on the mechanisms for strengthening social and relational capability. This can be done, among other things, by focusing on collaborative practices and shared experiences as well as work routines, which enable multiple professionals and other organisational participants to smoothly work together, at the various levels identified above. This, in turn, means that complex tasks and events, such as setting priorities, making trade-offs, making things more efficient, are not necessarily dealt with by individual professionals. Involving others – varying from colleagues to managers – referring tasks to others, speaking up and out, these are all part of professional action. Professional agency does not merely imply maximising individual professional leeway and action, but also restricting leeway and action, if and when necessary.

Conclusion

Traditional discourses on professionalism and professionals are highly attractive. They highlight the importance of well-trained experts who treat cases and serve society, at the same time. They accentuate the importance of reliable public services, also backed up by rituals, ceremonies and symbols. They enable professionals to intervene, with authority, in complex matters such as health, safety and education. These discourses have become problematic in the era of enterprise. Businesslike and market surroundings, also in public domains, have put lots of pressure upon professional action, as the symbols, ways of working and skills of professionals are at odds with new demands – efficiency, financial soundness, innovation and outputs. This has generated lots of conflicts and clashes, which – at best – might lead to peaceful co-existence, for example when there is ‘pragmatic collaboration’.

This chapter argued that we can go beyond these oppositions and dichotomies, not so much by linking conflicting logics and managing conflicts, but by renewing discourses on professionals and reconfiguring professional action. More specifically, we stressed the importance of turning case treatment and especially professional–client interactions and their quality into a relative phenomenon; of focusing on work flows in which such interactions are part of collective action; of co-ordinating multiple work flows, as professionals face multiple cases; of contextualising professional action, especially by including the judicial and political dimensions of case treatment; and of emphasizing the multiplicity of quality. Protecting professional work spaces as well as merely combining professional and performance logics is not enough. It might be useful to go beyond an emphasis on individual professionals, toward collegial professionalism; to go beyond images of strict performance regimes, toward the meaningful improvement of professional action; and to go beyond the assumption that performing better is an organisational matter, toward the acknowledgement that professional services are unavoidably organised. Quality resides in how organising takes places, on a day-to-day basis, by managers, professionals and other stakeholders.

These (mental) changes not only produce more realistic – and optimistic – images of professional action, they also turn professional action into a healthier affair, as individual professionals acquire more reasonable proportions. Public services still depend upon well-trained experts, but ‘the’ individual and autonomous professional is no longer seen as the grand and pure embodiment of professional public services. He/she is viewed as a crucial participant in coorganising joint professional action. This makes professional lives more interesting and more liveable – especially in the harsh and demanding era of enterprise.

Acknowledgement

Thanks are given to Evelien van Leeuwen, student-assistant at the University of Utrecht, for her editorial support.

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