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Introduction
Health systems worldwide are under pressure to perform. Performance in this instance is defined as efficiency, service quality and patient safety ([32] Sorensen and Iedema, 2008). However, quality failures and costs continue to mount, and government focus turns increasingly on the performance of health services themselves as the problem. As it does, political agendas pervade ever more deeply in to the operational realms of clinical workplaces, traditionally the preserve of the health professions. Health service delivery thus becomes a contested arena as powerbrokers vie for control. As instruments of government policy, health administrators seek to limit cost increases to keep spending on health care within sustainable limits. Clinicians, on the other hand, accustomed to more permissive practice environments, resist such constraints, aiming instead to maximise their professional autonomy and minimise organisational accountability. The impact of these different stances on health service performance can be profound.
Health reform policy attempts to bridge the gap between these seemingly opposing aims, and research interest is turning to the impact of policy implementation, as fertile grounds for exploration. One research direction quantifies the differences between sub-cultures to highlight the problems ([10] Degeling et al. , 1998); our interest is to describe them, to understand where the differences lie so as to lessen the distance between the stances of powerful stakeholder groups, specifically the relationship between administrative and clinical managers. We believe that by doing so, health service performance will improve. In this paper, we report on a qualitative study of senior administrative and clinical managers in a large tertiary referral hospital in Sydney Australia to gauge their stances on aspects of health reform policy and its implementation. We contextualise the paper with a selected literature review of reform policy and its implementation, the environments within which health services operate, the tenor of the relationship between administrators and clinicians and the strategies commonly used to improve health service performance.
Background
Implementing health reform
Health systems worldwide experience similar failures in quality, notably in the developed systems of the US, UK and Australia ([13] Forster, 2005; [21] Kennedy, 2001; [22] Kohn et al. , 1999). Policies to address these failures also tend to be similar ([29] NHS Executive, 1998). In Australia, health reform policy is structured around key themes...