Introduction

Across countries healthcare systems respond to new needs and demands with the introduction of marketisation and new public management regimes, including a number of performance indicators and benchmarks operating at a meso level of professional governance as well as improved user participation both in the policy process and clinical decision making. These strategies bring about greater control of providers and enhance transformations towards more demand-led services. There is still much controversy, however, especially over the benefits of professional self-regulation and the options of new governance to shift the balance of power away from the medical profession (Davies, 2006; Gabe et al, 2006).

This chapter attempts to highlight the transformability of the ‘private interest government’ (Moran, 1999) of professions and how it is targeted by institutional pathways of changing professional governance. It brings into view the linkage between policy and professionalism and a potential for modernising health systems. This approach moves beyond the controversies of marketisation/bureaucratic regulation, and the submergence/convergence of health systems and focuses instead on the role of the professions as ‘mediators’ between the state and its citizens.

The German health system serves as a case study to assess the dynamics of health reform in a non-Anglo-American context, and to explore a nation-specific set of policy drivers. Empirical material comprises document analysis, a questionnaire study of physicians and qualitative data on physicians, physiotherapists and surgery receptionists (Kuhlmann, 2006). While Bismarckian social policy, especially healthcare, epitomised models of social security and justice for about a century, nowadays a corporatist structure is viewed as a barrier to innovation. At the same time, elements of corporatism and professional self-regulation allow for flexibility and responsiveness and may ‘buffer’ social conflict (Stacey, 1992); they are even gaining ground in state-centred health systems (Hunter, 2006). Germany thus provides an interesting example to study both the weaknesses and benefits of professional self-regulation and how they interface with institutional contexts.