The thesis of this short communication is simple. It is that management in health care has, inescapably, a political dimension which is bound to affect both style and objectives. The importance of the political dimension may vary from country to country, depending on the way in which different systems are organized and financed: in particular, their publiclprivate mix of services. Equally, it will differ depending on the position of the manager in the organizational hierarchy: the management of health care systems (whether national, regional or local) raises somewhat different issues from the management of individual health care institutions. But, this paper argues, management everywhere in health care is political in the fundamental sense of involving decisions about who gets what and a continuing debate about the values that ought to shape its activities. In short, health care is about the allocation of scarce resources according to contested criteria. It therefore involves-potentially at least-conflict about both means and aims. In turn this point, if accepted, suggests that the management of health care is about the management of social and professional conflict.
In all this, the key is the obvious fact that health care-certainly in the countries of Western Europe-is predominantly publicly financed, whether through the tax system or insurance schemes. The proportion so financed varies from over 90 per cent in Britain to 70 per cent in the Netherlands (Maxwell, 1981). But the shared preoccupation everywhere, as we all know only too well, is to limit the financial commitment: to contain what is known as the 'costexplosion'. Indeed, the growing concern with innovation in management reflects this worry: good management-or so in Britain, at any rate, it is argued-can stretch available resources further. It is this worry, certainly, which explains the British Government's eager acceptance of the Griffiths Report (DHSS, 1983; 1984) and its radical recommendations for a shake-up in the managerial style of the National Health Service (NHS). The efficient manager is the new d e w ex machina who is going to save the NHS from the consequences of the failure of his predecessor in that role, the doctor, to deliver the goods. Medical science has not only disappointed the earlier, naive, belief that its miracles would liquidate the burden (and costs) of illness and disease; but, it has also demonstrated its capacity for generating new demands.
If all this is platitudinously self-evident, some of the implications are not. For it helps to identify why management in health care is peculiarly difficult, as well