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This article looks at US experiences of the contracting-out form of privatisations, the problems it can cause and the forms of resistance that have developed among public service unions. It focuses in particular on how the municipal workers' union in Indianapolis combined resistance with partnership to avert privatisation and achieve improved service, employment guarantees and better pay and working conditions. It then details, with reference to airport security, some of the perils of allowing privately owned companies, with their limited business preoccupations, to manage an area with a major public-good component.

When free‐market zealots succeed in turning over government services to profit‐making corporations, workers and citizens often suffer.

Public sector reform has found what many would see as unlikely champions, argues Brendan Martin - the public sector workers and their unions. Caricatured as bent on defending their power and privileges, they have in recent years come up with original and imaginative ideas on how to deliver high-quality, low-cost services. The key lies in trusting the front-line staff, and allowing them a lot more say in designing, and controlling their work. Not surprisingly, this has met with resistance from managers and politicians. Many of them are now showing that their real concern was political - a deep-rooted hostility to any form of collective provision - or financial - focusing on costs, rather than cost-effectiveness. Brendan Martin backs his case by looking at two rival models: the Tilburg model, based on a town council in the Netherlands, which turned a budget deficit into six annual surpluses by consulting and involving staff and unions; and the Lewisham model, based on the inner London borough of Lewisham, where the local authority earned awards for its clean streets, but at the price of mass lobbies, strike threats, and a soured industrial relations atmosphere. The Tilburg model is creaking now, as Brendan Martin concedes. But it, rather than the Lewisham approach, has pointed the way forward and has been developed by other local authorities in Europe. And he argues that it focuses attention on the real questions: how do we measure value in the public services? When we use those services, are we citizens or clients or customers? And how do we balance the three imperatives of keeping costs low, and quality and labour standards high?

Die Reform des öffentlichen Sektors hat Befürworter gefunden, die viele kaum erwartet hätten, so argumentiert Brendan Martin - die Beschäftigten des öffentlichen Dienstes und ihre Gewerkschaften. Sie werden oft karikiert als Verbände, die sich an ihrer Macht und an ihren Privilegien festklammern, aber sie haben in den letzten Jahren originelle und einfallsreiche Vorschläge darüber unterbreitet, wie sie hochwertige und günstige Dienste anbieten können. Der Schlüssel liegt darin, dem Personal vor Ort zu vertrauen, ihm viel mehr Mitsprache beim Entwurf und bei der Kontrolle seiner Arbeit einzuräumen. Das ist keineswegs überraschend auf den Widerstand des Managements und der Politiker gestoßen. Viele von ihnen zeigen heute, daß ihre wahren Beweggründe politischer - eine tief verwurzelte Feindschaft gegenüber jeder Form kollektiver Versorgung - oder finanzieller Art waren, focussierend auf Kosten und nicht auf Kosteneffizienz. Brendan Martin stützt seine Argumentation, indem er zwei entgegengesetzte Modelle untersucht: das Tilburg-Modell, eine Kommunalverwaltung in den Niederlanden, die durch Anhörung und Beteiligung des Personals und der Gewerkschaften in den letzten sechs Jahren ein Haushaltsdefizit in Jahresüberschüsse verwandelt hat, und das Lewisham-Modell, ein Stadtteil im inneren Einzugsgebiet Londons, dessen Kommunalverwaltung Auszeichnungen für ihre sauberen Straßen erhielt, was jedoch auf Kosten von Massenprotesten, Streikdrohungen und angespannten Arbeitsbeziehungen erfolgte. Das Tilburg-Modell bekommt die ersten Risse, wie Brendan Martin eingesteht. Es hat jedoch im Gegensatz zum Ansatz in Lewisham den Weg nach vorn gewiesen, den anderen Kommunen in Europa ebenfalls befolgt haben. Er argumentiert, daß es die Aufmerksamkeit auf die wichtigen Fragen lenkt: wie messen wir den Wert in den öffentlichen Diensten? Sind wir Bürger und Kunden, wenn wir diese Dienste in Anspruch nehmen? Und wie können wir die drei Anforderungen, die Kosten niedrig und die Qualität und die Arbeitsnormen hoch zu halten, miteinander vereinbaren? (Transfer / FUB)

OBJECTIVE: To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals. DESIGN: Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data. Setting: 87 acute care hospitals in Illinois. PARTICIPANTS: 210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital. MAIN OUTCOME MEASURES: Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios. RESULTS: Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse's workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse's workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million. CONCLUSIONS: Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

INTRODUCTION: Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public's health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing. METHODS: Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout. RESULTS: Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. CONCLUSIONS: Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public's health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.