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

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.