1. WHAT DOES THE PUBLIC SPHERE OFFER US?

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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%

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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