McTernan on politics

Who should provide public services? A loud public debate is raging
about the appropriateness of private providers providing core
services in the NHS. However, it has cast little light on the
fundamental questions. The crude way in which those on both sides
polarise the argument into public is good, private is bad or vice
versa belies the complex nature of the NHS. For example, nine out
of 10 visits to the health service are to GPs, and the bulk of them
are self-employed private contractors. Equally, for all the shock
and horror expressed about private firms making money from the NHS,
profit has always been made out of health – community pharmacies
and big pharmaceutical companies alike are crucial parts of the
NHS, yet are run for profit.

In stark contrast, there is a quieter but much more subtle
conversation about the potential for the third, or voluntary,
sector to play a much more substantial role in public service
delivery. The Association of Chief Executives of Voluntary
Organisations have just published a pamphlet Replacing the
State?¹ which makes an important contribution to
this debate. Indeed, as they point out, large areas of social
housing, social care and child care are already delivered by
not-for-profit organisations. So if, in many ways, they are pushing
at an open door where will the next great expansion come? Education
is one possible area – although fraught with potential pitfalls.
There is already substantial voluntary sector involvement – in the
state sector through church schools; and in the private sector
through charitable foundations. Further expansion in provision
could only come through a radical voucherisation of county schools
or extending local authority support to established providers.

A more likely expansion is the area of health. There has been much
focus on private companies coming into the NHS to run core medical
services. Less noticed has been the desire of the Department of
Health to entice US not-for-profit health care providers to
consider coming to the UK. US not-for-profits are big players.
Premier Health Care, for example, have 60 million patients – just
about the same size as the NHS.

There is, however, need for a note of caution. Julia Unwin points
out that past successes in service provision have been because
users and communities have used voluntary action to challenge
monolithic service provision. These perspectives must not be lost
otherwise the voluntary sector will end up merely providing mass
services at a slightly lower unit cost.

¹ Julia Unwin, Replacing
the State? Association of Chief Executives of Voluntary
Organisations, 2003

John McTernan is a political analyst.