Repositioning the boundaries between public and private healthcare providers in the English NHS

Health sector ‘reform’ has re-opened the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. Using new data from England this paper considers: 1. How do the internal managerial regimes of differently owned healthcare providers differ, or not? 2. In what respects did any such differences arise from differences in ownership or for other reasons? Observational systematic qualitative comparison of a maximum-variety (by ownership) sample of community health services (CHS); out-of-hours primary care (OOH); hospital planned orthopaedics and ophthalmology providers (N=12 cases). The framework of comparison was a set of ownership categories related to current NHS policy. Top-level governance structures diverged by organisational ownership and objectives. At operational level all the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways. This study was empirically limited to just one sector in one country, although within that sector our case-study organisations were typical of their kinds. It focused on formal structures, omitting to varying extents other technologies of power and the differences in care processes and patient experiences within differently-owned organisations. Type of ownership does appear, overall, to make a difference to at least some important aspects of an organisation’s governance structures and managerial regime. For the broader field of health organisational research these findings highlight the importance of the owners’ agency in explaining organisational change. Our findings also call into question the practice of copying managerial techniques (and ‘fads’) across the public-private boundary. This paper is one of the few to examine empirically what difference ownership makes, to the management of health organisations.