Scale, Distance and Performance Management - The Invention of the “10-Minute Patient” and the Composition of Medical Practices

Performance management requires techniques of management – such as accounting systems – that draw disparate elements together, make them comparable, relate them in new ways, and create accountabilities (Kirk & Mouritsen, 1996, Mourtisen, 2001, 2005, Jones & Dugdale 2002, Quattrone & Hopper 2006,). This view – which builds on parts of actor-network theory (Latour, 1986, 2005, Law, 1996) – understands such techniques as ones that put events and activities on a similar scale so that, even if they are different, they can be juxtaposed, combined and integrated via writing, recording and counting. Performance management requires such techniques, typically in the form of accounting systems, because they enable, if only imperfectly, putting together things that were previously separated. In this way, performance management is concerned with inventing new objects by giving existing objects a similar scale so that they can be superimposed on each other. The effect is that new objects are made manageable by such an operation. Performance management is therefore not concerned primarily with describing the world; it is more importantly concerned with intervening in the world and transforming it. In this chapter, we illustrate and discuss the implications of such a rationale through an analysis of selected changes in the Swedish public sector since the 1990s (SOU 2001:79, Olson et al. 1998). Like many other countries, Sweden has gone through many reform programs with the aim of increasing efficiency and effectiveness in the use of scarce resources. Specifically in the health sector, accounting techniques such as Diagnosis Related Groups (DRG), responsibility accounting and performance measurement have been widely discussed and implemented. But how would accounting and performance management be able to create efficiency? How do they convince managers, politicians, users etc. that they carry relevance in relation to this end? This is no simple affair. One possibility is that a sceptical audience may be persuaded by accounting’s appeals to objectivity, suggesting that accounting captures the world and presents it in financial value. This may not always be enough in order to convince, however, because objectivity – if it is there – is a proposition about the past which is seen to be described truly and fairly. But reform programs are not about the past. They concern the introduction of new practices and are therefore about the future. The power of accounting would then be to help transforming and changing areas such as the health sector. The power of accounting, therefore, is predicated on linking activities that are spread across time and space in new ways. It is predicated on its ability to legitimately speak for others, to manoeuvre contexts, to redesign operational matters. Accounting techniques enable performance management not primarily because they represent an underlying reality of operating activities. Rather, they enable performance management because they suggest that ‘the underlying reality’ could be different. By this, they motivate an agenda of change and transformation. Accounting helps to produce – rather than copy and describe – entities in such a way that they can be related to other entities in new and surprising ways.