WHAT DOES THE PUBLIC SPHERE OFFER US?

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WHAT DOES THE PUBLIC SPHERE OFFER US?
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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

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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)

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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

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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

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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 its our building
• Result-
• time-consuming failure reporting system
• Teamwork more difficult to establish
• Loss of quality and responsiveness
• Sense of belonging endangered

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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)

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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.

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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

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Broken promises

• Logic of commercial involvement profit made at
  public expense in exchange for superior service
  provision. Win-Win.
• BUT this isnt happening in health
• So why are they there? Revalorisation

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• 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.

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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

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