WHAT DOES THE PUBLIC SPHERE OFFER US?

The public sphere and the UK health sector Examining recent reforms in the English NHS draws attention to the weaknesses of the private sector and some of the strengths of the public

Recent reforms in English health system Restructuring of NHS as open competitive market Payment by results Diverse providers – including private companies Routine surgery contracted out to private ‘treatment centres’ (ISTCs) New hospital facilities procured under Private Finance Initiative (PFI)

Claims to greater efficiency in the private sector Private sector is often NOT more efficient that public sector PFI – very complex and expensive way of procuring new facilities ISTCs – much simpler contracts but still more expensive than NHS care Support services – cleaning, catering etc

What does this tell us about the public sector? In some areas at least, it is more economically efficient that the private sector and more socially efficient

Thinking about public service work more holistically Transfer of support workers in context of PFI hospital Multiple on-site employers Poorer terms and conditions for private employees Increased workload Tighter managerial control of labour process to cut costs Less freedom – ‘it’s our building’ Result:- time-consuming failure reporting system Teamwork more difficult to establish Loss of quality and responsiveness Sense of belonging endangered

What does this tells us about the public sector? Integration of the workforce aids teamwork, responsiveness and quality Work not disrupted, distorted or made irrational by profit motive Hidden features – ‘regimental spirit’, acting beyond contract ‘courtesy and sociability have a therapeutic effect’ (Titmuss, 1958)

The importance of an integrated service Market and diversity of providers lead to fragmentation Affects continuity of care for individual May threaten long term sustainability of universal comprehensive service by undermining principles of cross-subsidy and risk pooling

What does this tell us about the public sector? Tax-funded monopolistic public health care provider avoids fragmentation and sustains universalism through risk pooling and cross subsidy

Market and diversity of providers is expensive to manage and administer Lack of research but costs of administering and managing new NHS market estimated between 12% and 20% 1970s 5-6%

What does this tell us about the public sector? An integrated monopolistic health service is relative cheap to administer and manage and thus more efficient

Risk averse nature of private sector organisations Commercial organisations are risk averse. Profit margins are easier to secure where there is predictability. But much health care is relatively unbounded

What do we learn about the public sector? Through risk pooling and cross subsidy underpinning a monopolistic service, the public sector is able to embrace risk, to treat patients equitably and use resources for patient care

Unsuitable nature of the contract Contracts fix terms – often expensive to re-open for renegotiation But many private sector contracts problematic E.g. PFI (30yrs) and ISTCs

What does this tell us about the public sector? Public services need to evolve organically in response to changing demography, changing need, changing public expectations, changing policy context, changes in policy, changing attitudes, values and mores and so forth. Public sector organisations can evolve more gradually without imposing extra costs.

The public sphere and social integration Social efficiency requires a reasonable degree of social integration Inequality and difference threaten social integration Public sphere enhances social integration through redistribution – ‘social wage’ Public services offer shared spaces for shared experiences

What does this tell us about the public sphere? It reduces economic and social inequalities and plays a vital function in enhancing social integration and reinforcing community. The integrative effects of public services will be stronger where there are shared public service values and purposes

The public sphere and democratic accountability Private companies seek to restrict the amount of information in the public domain on the grounds of commercial confidentiality. Cross-overs between commercial sphere and public sphere This undermines scrutiny by citizens, independent academic assessment and formal democratic scrutiny.

What does this tell us about the public sphere? The public sphere is the only sphere in which democratic accountability is possible. Blurring boundary between commercial and public undermines weakens ability of the public to define and safeguard the public interest An expanded public sphere in which more aspects of life are determined through the democratic process can reinvigorate political engagement

Broken promises Logic of commercial involvement – profit made at public expense in exchange for superior service provision. Win-Win. BUT this isn’t happening in health So why are they there? Revalorisation

Public sphere does not guarantee rational, economic, socially efficient and democratic services but it is the only sphere which can have any hope of securing them.

Winning back ground from the private sector Articulate the strengths and superiority of the public sphere; develop a much stronger critique and disseminate it Develop a positive agenda for change Highlight private sector failings Show investors there are financial and reputational costs