Can French public hospitals make do with a dynamic and uncertain environment by developing inter-organizational restructuration strategies?

For a few years, public hospitals in France and in most of developed countries have had to deal with major issues. New legislations have recently been introduced, such as a prospective payment system (PPS: hospitals are reimbursed depending of the amount of services they provide), which aims at developing "business-like" management models, according to the New Public Management principles (Osborne & Gaebler 1994). Therefore, the dominant institutional logic in healthcare organizations is shifting, sometimes in very short periods of time, from "medical professionalism" to "business-like healthcare" (Reay & Hinings 2005). The PPS is a pro-competitive trigger, since hospitals are encouraged to develop their activity in order to generate more income by gaining market shares (Moisdon 2013). What is more, public hospitals often have to cope with a major problem of medical workforce shortages (Kroezen et al. 2015), which threatens the existence of some activities in a lot of institutions, particularly in remote areas. Furthermore, the evolution of medical practices, for instance the ambulatory turning point which consists in reducing, when possible, patient stay in hospitals to less than 24 hours, brings about a series of organizational concerns, as hospitals will be asked to cooperate with different stakeholders about healthcare pathways. All in all, as in many developed countries, hospitals are pressurized into providing better care at an affordable cost, in a dynamic and uncertain environment, with potentially clashing demands. In order to generate a transformation of the French public hospitals territory organization, and so as to meet the challenges mentioned above, the French government has implemented a set of tools aiming at fostering restructuration between neighbouring hospitals, thanks to cooperation and merger processes. For instance, a law voted in 2009 provided hospitals with the possibility to cooperate in Territory Hospital Communities. Private clinics have been dramatically restructured in the past two decades amongst integrated networks, but public hospitals, which have been used to working relatively autonomously, have not followed this process to the same extent in France (Delas 2011). The results that the government was calling for have not been rather mixed so far. Given this relative failure, the State has decided to step up a gear by making cooperation mandatory. By the end of 2016, all hospitals will have to be part of a Territory Hospital Group. Territory organization of healthcare providers is regulated by Regional Health Agencies (RHA), whose mission is to promote restructuration leading to a better access to healthcare at an affordable cost. The purpose of this paper is to contribute to the management literature about organizational change implementation in the case of inter-hospital reorganization, by analysing restructuring processes under way in France. The empirical material collected will be used to answer the following research questions: 1. To what extent are inter-hospital restructuring strategies an answer to uncertainty (such as the lack of medical resources) and pro-competitive triggers (e.g. the PPS) they have to cope with? 2. Is the transformation of the French public hospitals territory organisation led thanks to a regulated restructuration process, or is it the result of "making do" bottom-up strategies (sometimes partially unsuccessful) between hospitals? The study was carried out thanks to two different case studies that analysed inter-organizational restructuration strategies in two French public hospital groups. Qualitative data was collected mainly by carrying out 30 semi-structured interviews with different stakeholders involved in the processes. This paper shows that even though the necessity of performing inter-hospital restructuration in globally accepted by the different stakeholders, the conditions to implement this process raise a number of concerns. The role and missions of the regulatory institutions is not always clearly defined. Moreover, because of multiple factors that will be presented, it may be observed that inter-hospital restructuration is more often the result of "making do" bottom-up strategies, with uneven results, rather than that of a rational and wider regulation.