Professionalisation, policy networks and the development of French health policy : the rise of hospital directors, the Syndicat National des Cadres Hospitaliers, 1976-1991
As governments have grappled with the demands of cost containment policies in health care, a series of challenges have arisen to the 'privileged' position of medical professionals in public health care systems. Hospital managers and administrators have contested medical control of the health policy agenda and the allocation of resources. This managerial challenge raises important questions about how new groups or lobbies have emerged in health policy-making, and about the capacity of governments to induce change within professional policy networks. The thesis explores these issues by analysing the development of French hospital management policy from initial measures towards cost containment launched in 1976 to the complete re-writing of previous legislation on public hospitals in 1991. The policy networks shaping hospital management policy have been transformed by the development of the French corps of public hospital directors and its largest trade union, the Syndicat National des Cadres Hospitaliers (SNCH). Through the 1980s, the SNCH evolved its own programme for hospital management reform, and its members rose to occupy pivotal positions during the decision-making process which led to the 1991 Hospital Law. The thesis highlights the role of politicians in transforming policy networks by making top-down changes in the regulation and financing of policy systems, and by fostering bottom-up changes in the balance of influence between professional groups and in the local management of hospitals. In addition to political influence and contingent professional changes, the study examines how policy systems can have their own logic of development, which powerfully shape long-run patterns of change in the health policy sector.