The complexity of governance change: reforming the governance of medical performance in Germany

The governance of medical performance is changing and new governing instruments are emerging. Existing analyses highlight the complexity of new governance arrangements, but the more or less dualistic perspective limits the possibility for exploring more fully this complexity. The present article therefore uses recent contributions to the literature on governance to explore the co-existence of different forms of governance with the aim of assessing the relative extent and the substantive nature of governance change. Using recent reforms of the governance of medical performance in Germany as a case study, the analysis suggests that the complexity of governance change takes three forms: first, the balance among (hybrid) forms of governance is shifting; second, the nature of individual (hybrid) forms of governance is changing; and, third, both types of change are reflected in tensions not only between but also within (hybrid) forms of governance. As such, the article also contributes to the recent literature on governance by highlighting the centrality of tensions in contemporary governance, which can also occur within both hybrid forms of governance and `pure' forms of governance.