Elsevier

Social Science & Medicine

Volume 74, Issue 3, February 2012, Pages 313-322
Social Science & Medicine

Public, private, neither, both? Publicness theory and the analysis of healthcare organisations

https://doi.org/10.1016/j.socscimed.2011.07.021Get rights and content

Abstract

In England recent health reforms have resulted in a shift of emphasis from targets to outcomes, and to the provision of healthcare by any willing provider. The outcomes described encompass clinical and public service outcomes such as choice and access. The range of organisations providing healthcare services is large and increasing. Whilst many are clearly located in either the public or private sectors, others have features of both public and private organisations, and are not easily characterised as either one or the other.

Analytical frameworks are generally underdeveloped, and have not kept pace with changes in organisation forms. This article reviews how public and private organisations have been compared in organisation theory, describes previous work on dimensional publicness in both non-healthcare and healthcare organisations, and presents a publicness grid for hospitals in England. Publicness is defined as a characteristic of an organisation which reflects the extent to which the organisation is influenced by political authority.

In establishing a link between publicness and public service outcomes it is suggested that core publicness, dimensional publicness (consisting of political and economic authority) and normative publicness (public sector values) all have to be taken into account, since all have an impact on these outcomes. A framework is described that can be used to map the relationships between public service outcomes and publicness.

How the framework can be applied in practice to healthcare organisations is described through the development of appropriate indicators and measures. Publicness theory can help health administrators and researchers understand and better manage public service outcomes. Some of the research questions that might be addressed using this approach are considered. Further development of the publicness concept in healthcare is advocated.

Highlights

▸ Recent English health reforms have resulted in a shift of focus from targets to outcomes and to provision of care by any provider. ▸ The wide range of organisations now providing healthcare services are not easily classified as either public or private. ▸ A publicness grid for hospitals locates them according to the extent of their political and economic authority. ▸ A framework is given linking core, dimensional and normative publicness and their indicators to public service outcomes. ▸ Publicness theory can help health administrators and researchers understand and better manage public service outcomes.

Introduction

The nature of healthcare organisations has undergone enormous transformation in recent decades, with new organisational forms emerging in many countries. In England, for example, National Health Service (NHS) Foundation Trust hospitals have been created as a new form of independent legal entity, called Public Benefit Corporations. They are ‘set free from central government control, and are no longer performance managed by Health Authorities.’ In addition ‘they have new financial freedoms and can raise capital from both the public and private sectors within borrowing limits determined by projected cash flows and therefore based on affordability. They can retain financial surpluses to invest in the delivery of new NHS services’ (Department of Health, 2005).

More recently the government has indicated its intention to move away from performance management systems based on targets to approaches focused firmly on outcomes (Department of Health, 2010a). Such outcomes encompass a broad range, from clinical outcomes (such as cancer and stroke survival rates) to public service outcomes (such as improved patient experience and culture openness). There is explicit recognition that these outcomes may be delivered by private providers as well as by the public sector. A system focused on improving outcomes, it is claimed, involves ‘robust economic regulation and quality inspection, an enhanced local voice, clinically-led commissioning and payment for results, empowering professionals working in autonomous providers, and informed patients exercising choice’ (Department of Health, 2010a).

This increased emphasis on outcomes is being applied across government departments, with a drive towards better outcomes for all service users and citizens. For the NHS outcomes have been defined by an Outcomes Framework (Department of Health, 2010b). This spans five so-called domains of quality: ‘preventing people from dying prematurely; enhancing quality of life for people with long-term conditions; helping people to recover from episodes of ill health or following injury; ensuring that people have a positive experience of care; and treating and caring for people in a safe environment and protecting them from avoidable harm.’ These encompass both clinical outcomes, focussed on individual patients, and broader patient service outcomes such as quality of care. An explicit link is made between patient service outcomes and public values such as access and choice. It is claimed that good patient outcomes require that ‘health and social care services are better integrated, patient choice is extended, and that unnecessary barriers to new provision are removed’ (Department of Health, 2010c).

These developments raise important questions. Are public service outcomes best delivered by public sector organisations, or can private sector ones do so equally well? What organisational characteristics are required to deliver public service outcomes? And what can health service managers do to facilitate the effective delivery of such outcomes? Organisation theorists have been grappling with these issues for many years. But a branch of organisation theory has been developing that shows promise in not only accommodating the diversity of organisational types across all sectors but also linking these to public service outcomes. This is publicness theory, and frameworks are being developed that allow these questions to be addressed.

The purpose of this paper is to explore how such questions might be addressed, and to demonstrate how the application of publicness theory can help health administrators and researchers to understand and thus better manage public service outcomes in healthcare organisations. It has three main parts: “Comparing public and private organisations” reviews how public and private organisations have been compared in organisation theory, before describing a framework for mapping the relationships between public service outcomes and publicness; “Publicness studies in non-healthcare organisations” reviews previous work on dimensional publicness, in both non-healthcare and healthcare organisations; and “Applying the publicness framework in practice” considers how the framework can be applied in healthcare organisations, before considering some of the research questions that can be addressed using this approach.

Section snippets

Comparing public and private organisations

A large body of research has now compared public and private organisations, using a variety of approaches. The purpose of much of this has been to consider whether one type of organisation is more effective than others in delivering certain outcomes. Other studies have examined the extent to which particular organisational attributes are specific to one sector or are shared across several. Scott and Falcone (1998) reviewed the underlying conceptual frameworks used in these studies, and

Publicness studies in non-healthcare organisations

Relevant variables are to be found in many of the publicness studies that have now been reported. Most of those carried out in healthcare organisations have been based on core publicness approaches, and are considered below. Selected studies in non-health related organisations are summarised in Table 1.

According to Bozeman (1987) the key to the ‘publicness puzzle’ (whether the public context of organisations affects their behaviour) lies in the organisation’s mix of political and economic

Applying the publicness framework in practice

Dimensional publicness can be illustrated graphically. Bozeman used data from his 1987 study to plot a publicness grid for research and development organisations in the United States. The grid located organisations on two axes, economic authority and political authority. Traditional government organisations were seen as having high political authority combined with low economic authority. Owner-managed firms were the reverse, having high economic authority combined with low political authority.

Conclusion: challenges and opportunities for healthcare

The driving force behind recent changes in healthcare policy in England has been the need to improve performance. The implicit assumptions underpinning FTs are that the more autonomous hospital organisations are, the better will be all aspects of their performance; health services will be better when delivered by FTs than by organisations under closer central control. Yet the literature on organisational performance indicates that there is no consistent relationship between matters such as the

Acknowledgements

I wish to thank the three anonymous reviewers whose rigorous critiques of the manuscript have greatly enhanced the paper.

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