Table 3

How the justification to contract out/not to contract out is formulated and what is the interviewee position in each frame, description and data extracts
“Rational” reasoning Pragmatic realism Promoting diversity of the providers Benefits for the municipality Good for the local people
Justification to contract out The decision to contract out is a rational decision based on strategic planning and careful considerations taking into account the good of the municipality as a whole. The decision makers are forced to choose an alternative, which from their point of view, is suboptimal or undesirable, but which is the only possible alternative in the present situation. Outsourcing is a means to create provider diversity in order to improve quality and efficiency, gain cost-savings and create benchmark for public providers. In addition, diversity is seen as a source of flexibility and citizen choice. Outsourcing is seen as a tool to boost municipal economy through job creation and increased tax revenue. Outsourcing is seen as a means to ensure high quality, tailor-made services and to provide choice for the citizens.
Example “The planning takes into account the whole range of services, what there is available in the area and what we might possibly need more. Is it worthwhile to renovate the long-term hospitals that have been transferred to us and to what extent, how much we could preserve in the hospital area and how much it will cost or whether there’s the option of abandoning the service and buying it. I mean we are planning all the time and this is one of the manifestations, we try to look at different areas of Helsinki for what the situation is.” (Civil servant) ”We have this chronic problem that our older people are in completely wrong places, in wards in the regional hospital or health centres, and this will also lead to a fairly rapid institutionalisation of elderly patients. In a way the A&E department is a strategic key process used to direct older people with many illnesses into the orbit of specialized health care. And as we are dealing with people who do not know the services and as the municipality is ‘saving’, so to speak, and the A&E services are cheaper when contracted out. But we will get the bill through specialized health care and institutional care for older people.” (Civil servant) ”Our model of multiple providers is a way of benchmarking our own provision against another provider to see whether there are new ways to provide services. I must admit though that this public system is pretty rigid in terms of reforms. In a way we must get some evidence that the work can surely be done in some other way.” (Civil servant)“The more actors, the more there will be different ways of doing things. I have swallowed the idea that in the future the only possibility in the social services field is to increase productivity at work. Competition is the thing that increases it, especially if you have small units, they will do things differently and they all try to work towards more efficient solutions. But as I said earlier we should be able to create such quality indicators that we could look at it not only from a purely economic viewpoint.” (Politician) “And it started to appear right from the start as a local employment scheme, which it is to the greatest extent. And as we’ve got high unemployment numbers in the area and high structural unemployment, we’ve always had it, there’s been very little discussion about it but it’s the thing that’s continuing to cause pressure in the background, that we should organise our operations in a way that would make visible our local employment and local need for jobs and to design systems that support local initiative.” (Civil servant) ”It probably is this”ageing in place”, the notion that the services somehow come closer to people, in the form of individualised solutions. The role of the municipality will become stronger in case management guidance, the role of the public sector as a promoter of solutions and as information and guidance services. And there will be countless ways to provide services and people will try to find solutions that suit them best and they will also pay for them.”(Civil servant)
Justification not to contract out The decision not to contract out is based on the view that there are certain core services, which the municipality is willing to preserve. The costs of out-sourcing are seen excessive compared to the perceived benefits. The decision makers are forced to choose an alternative, which from their point of view, is suboptimal or undesirable, but which is the only possible alternative in the current environment. In relation to the aim of the diversity, a certain amount of public provision should also be preserved.If there is excessive diversity the chances are that the service system becomes too fragmented and the coordination of the system may become difficult resulting in inefficiencies and extra costs. Not to contract out is seen as a tool to prevent multinational companies from obtaining a local monopoly and ruling the small local firms out of the market.Public sector wants to preserve its role as a good employer employing people in the area. It is seen that citizens should be protected from the market forces. There is willingness to ensure the quality and continuity of care.
Example ”Well certain official services should not be contracted out at the moment, at least not at the present moment, in the sense of responsibilities and other things. But we’ve seen some things, kind of strategic issues, too, that the city provides and operates. I don’t think it’s sensible to contract out all areas in our health care and social services field.” (Politician) We had a situation in C., I believe, there was a health centre which could not get a doctor for two years. We wanted to buy them physician services so that K. would get a doctor. They turned it down for ideological reasons because they think it will lead to inequality. Or I don’t know what the reason was but the plan fell through.” (Politician) ”And in our elderly services, how much did E. say, it’s quite preposterous what they’ve purchased. Fifty-four percent of the housing services. There actually is no room for further increase there. The municipality should have operations of its own to be able to benchmark.” (Politician) “It would be different if the actor in elderly services is a local business because we support local business activities. But the business in question that organises the physician services for the health center is a listed company and owned by foreigners, I believe. The tax collected from our municipal residents is not meant to be used for this but the activities should benefit the whole region, the local businesses, and we do not have such health care businesses.”(Politician) ”These are the resources that we are actually measuring. But you certainly need to have specific terms and conditions as the extreme horror scenario would be to return to the period of auctioned paupers, someone will make the lowest bid and the quality will start to suffer and our elderly citizens will be left without food. It’s just like wading through a quagmire you should have clear tools for measuring the quality. On no account should we leave them at the mercy of the market forces.” (Civil servant)
Interviewee position A rational actor who tries to defend the rationality of the decisions and to promote a comprehensive decision-making process despite external pressures influencing the decisions. Rational actor forced to adopt a pragmatic and realistic position towards the decisions as a means to adapt to prevailing environment An actor who is willing to create diversity of providers and alternatives for citizens as long as it improves providers’ operational measures and does not endanger public provision An actor who does what is best for the municipality as a whole. A actor who bases their decision on the notion of “the best of citizens”

Tynkkynen et al.

Tynkkynen et al. BMC Health Services Research 2012 12:201   doi:10.1186/1472-6963-12-201

Open Data