Abstract
Scholarship on power resources theory has often understood ‘institutional resources’ as restricted to labour market institutions, despite the concept of ‘institutions’ extending beyond the regulation of the labour market and into goods and services markets. During the pandemic, trade unions assumed such an important, extended role of co-managing functions beyond the labour market. However, under which conditions can unions effectively assume this extended role? We argue that an important condition is the existence of ‘political power resources’: political characteristics of a given field that empower unions to assume an extended role. We develop this new form of institutional power resource by examining the success of union-led, anti-privatization campaigns in German and English healthcare. In doing so, we explain why campaigns in England succeeded more than in Germany by virtue of the politics of the two countries’ healthcare systems: in England, the system’s high level of politicization prompted policymakers to follow anti-privatization campaigns and halt privatization; by contrast, in Germany, policymakers could legally circumvent anti-privatization campaigns.
Keywords
Introduction
Anti-privatization campaigns in healthcare – including by trade unions – have been vital in limiting and even halting privatization efforts (Greer et al., 2013b; Umney & Coderre-LaPalme, 2017). Halting privatization is important because market mechanisms aimed at increasing privatization have been associated with negative cost and quality outcomes (Krachler et al., 2022), like higher mortality rates through outsourcing (Goodair and Reeves, 2022). Healthcare trade unions have played a key role in anti-privatization campaigns, extending their role beyond ‘bread and butter’ issues to include service delivery issues. Particularly during the pandemic, unions assumed this extended role by representing essential workers and broadening their remit beyond labour market issues to ‘product’ market issues (i.e. the exertion of influence over the design and delivery of health services; Brandl, 2023; Meardi and Tassinari, 2022).
How, however, do power resources influence the success or failure of healthcare unions’ extended role, specifically, in pursuing anti-privatization campaigns? While institutional and other power resources have gained much scholarly attention as influential factors (Marginson, 2015; Rigby and García Calavia, 2018), scholars have also pointed to potential downsides for unions who rely heavily on institutional power resources like reduced capacities for member mobilization (Bernaciak and Trif, 2023) and collective bargaining (Kahancová and Martišková, 2023). It is therefore unclear whether institutional resources empower unions or not and whether unions should instead pursue other power resources.
Furthermore, institutional power resources have often been understood as derivative of unions’ labour market functions (Refslund, 2025), emphasizing employment relations (ER) institutions that empower unions, like bargaining levels and co-determination rights (Doellgast, 2008). For example, much research has focused on healthcare unions’ role in collective bargaining around the consequences of health reform (Galetto et al., 2014; Kahancová and Szabó, 2015; Stan and Erne, 2015). This is despite the term ‘institutions’ denoting a broader range of ‘norms and rules and resulting constructs which shape the interaction of economic actors and their associated interests’ (Rigby and García Calavia, 2018: 130) than only labour market institutions. In addition to its unique collective bargaining institutions (Bechter et al., 2012; Greer et al., 2013b; Krachler, 2023), however, the healthcare sector is also marked by its profoundly politicized character (Krachler and Greer, 2015; Umney & Coderre-LaPalme, 2017) which includes political factors like strong government intervention (Szabó, 2025), and partisanship (Bach and Bordogna, 2013; Kahancová and Szabó, 2015). Such political factors are also different from ‘ideational power resources’ which refer to ‘the use and construction of ideas and ideation to influence other actors’ (McLaughlin and Wright, 2024: 98). Political factors are thus likely to play an important role in the effectiveness of healthcare union campaigns, warranting more attention on the political dimensions of institutional power resources like contesting the design of reforms themselves (i.e. before reforms are implemented) or indeed, halting reforms altogether. To advance our understanding of institutional power resources’ role – and particularly of political factors as institutional power resources – for unions’ success in halting privatization, this article compares the success and failure of healthcare unions’ anti-privatization campaigns in Germany and England. German unions are often noted for having stronger institutional power resources than English or US-American unions, because of sectoral bargaining, worker participation rights in the workplace and corporate governance, their role in the administration of the welfare state (Doellgast, 2008). It is therefore surprising that English campaigns were more often successful than German ones. Our explanation of this puzzle lies in the politics of healthcare. While the vast majority of funding and provision is directly administered by central government in England, German healthcare is mostly funded by social insurance and provided by a mixed landscape of non-profit, for-profit, and public-sector entities. We argue that anti-privatization campaigners were more successful in England because of differences in constraints on, or conversely, facilitators of, unions’ anti-privatization campaigns that derive from these comparative differences of the politics of healthcare.
We argue that these dynamics demonstrate the importance of a new type of institutional power resource: ‘political power resources’ which refer to the extent to which the political structure of a given field constrains or facilitates trade unions’ representation activities. We therefore broaden our understanding of institutional power resources. In addition to this conceptual contribution, we provide evidence of unions’ ability to contest political reforms themselves – in addition to reform consequences – and conclude that trade unions should embrace this extended role of influencing product markets in addition to labour markets (Brandl, 2023; Meardi and Tassinari, 2022) where the political structure of a field is favourable.
In the remainder of this article, we first discuss the predominant understanding of institutional power resources as labour market institutions and how healthcare ER studies suggest we should pay more attention to political dynamics. After presenting our methodology, we then report our findings, discuss their significance, and conclude with the article’s implications.
Comparative perspectives on the success factors of union representation: Going beyond employment relations institutions
Traditionally, comparative ER scholars have conceptualized union success as strongly derivative of whether institutions focused on regulating labour market functions empower unions or not. While scholars might not have used the term, this approach suggested that institutional power resources were the primary influencing factor for union success. In line with the classic Varieties of Capitalism approach (Hall and Soskice, 2001), these studies have found that coordinated labour market institutions, such as board-level employee representation (Rosenbohm and Haipeter, 2019), industry-level collective bargaining, national co-determination laws and vocational training in Germany, empower unions more than liberal institutions like in the UK. For example, while US and German unions relied on member mobilization, ver.di drew on additional power resources from its works council to negotiate stronger collective agreements over outsourcing in the German telecommunications sector (Doellgast, 2008).
Moreover, while institutions were initially considered inert, scholarship on institutional change has shown that changes in national institutional arrangements can account for declining union effectiveness (Gumbrell-McCormick and Hyman, 2013). Relevant changes have been, for example, declining collective bargaining and works council coverage in Germany (Hassel, 1999), increased public-sector outsourcing (Mori, 2017) or lacking support from national unions and unionists’ limited knowledge of different national systems (Greer et al., 2013a). Similarly in the healthcare sector, reforms following the 2007/2008 financial crisis have reduced unions’ institutional power resources whereby governments have driven down working conditions to implement austerity programs (Bach and Bordogna, 2013), sometimes with structural reforms like Hungarian policymakers converting public hospitals into public corporations (Kahancová and Szabó, 2015).
Some scholars have argued that institutional power resources can reduce other power resources, potentially suggesting that unions should focus less on institutional power resources: with declining institutional power, a stronger need for framing and organizing could arise (Dupuis, 2017; Frege and Kelly, 2003) and/or institutional power resources can discourage drawing on associational power by incentivizing the use of traditional institutional channels (Baccaro et al., 2003) like legal protections (Bernaciak and Trif, 2023; Kahancová and Martišková, 2023). However, recently, scholars have somewhat softened this tension, arguing that organizing tactics can be adapted to suit the prevailing institutional environment (Nicklich and Helfen, 2019) and that institutional security can contribute to developing associational and other forms of union power (Rigby and García Calavia, 2018). Underlying this research on institutional power resources, however, is an assumption that labour market institutions are the primary sources of institutional power for unions.
ER studies on healthcare have suggested a potentially broader understanding of institutional power resources. Specifically, their emphasis on the sector’s political characteristics suggests that, in addition to labour market institutions, these political factors may also empower unions.
One such political characteristic is strong government intervention (Szabó, 2025), particularly through policy reforms (Krachler et al., 2022). While this is especially the case for National Health Service (NHS) healthcare systems in which regulation, provision and ownership of health services is public and therefore highly politicized and centralized, like in the UK (Böhm et al., 2013; Moran, 1999), healthcare unions have been politically active even in highly privatized systems, like the USA. For example, Givan (2016) documented how healthcare unions mobilized extensively in favour of staffing legislation in California and federal legislation around safer needle usage. In this way, the elevated level of government intervention in healthcare could permit unions to persuade policymakers to act in their favour, bypassing employers, and labour market institutions.
To sway policymakers, however, unions must convince them that they can upset policymakers’ aims and therefore potentially cause perceptions of electoral costs or other undesirable consequences. To achieve this, unions can generate support from the workforce by calling on healthcare workers’ public service, and often professional, motivations if unions can convince healthcare workers that a reform will contradict these motivations (Giaimo, 2002; Krachler et al., 2021; Umney & Coderre-LaPalme, 2017). Moreover, unions can plausibly threaten undesirable consequences for policymakers if they can convince service users that a reform will undermine efficient, high-quality health service provision. This is particularly the case in publicly dominated systems because they are founded on a solidaristic discourse of universal provision free at the point of provision (Coderre-LaPalme et al., 2023). German policymakers have been more effective at implementing financing reforms than British policymakers (Hacker, 2004), partly because the British NHS enjoys stronger public legitimacy and large-scale reforms have been associated with higher electoral costs (Klein, 2006; Krachler and Greer, 2015; Umney & Coderre-LaPalme, 2017).
At the same time, policymakers can mitigate union resistance to reforms by granting concessions. For example, the British Medical Association first supported dropping primary care physicians’ monopoly over out-of-hours care provision in 2004 because policymakers raised the medical profession’s incomes by complementing the reform with generous and easily achievable performance targets (Heins and Parry, 2011). Similarly, New Labour’s support of ER protections – the Two-Tier Code and the national collective bargaining structure ‘Agenda for Change’ – limited the negative wage outcomes of their marketization and privatization reforms (Galetto et al., 2014).
Overall, the above suggests that the traditional understanding of institutional power as primarily derivative of labour market institutions might be too restricted to explain union success in the healthcare sector. Specifically, healthcare studies suggest that the success of unions’ anti-privatization campaigns could depend on how effectively unions can harness the sector’s political characteristics to their advantage. The politics of healthcare matter, including the degree to which healthcare is politicized, the perceived electoral and reputational costs of privatization reforms, and whether policymakers can circumvent anti-privatization campaigns due to the nature of commissioning services. Before turning to our findings exploring these issues, we describe our methods.
Research design and methods
We studied the role of institutional power resources in influencing unions’ anti-privatization campaigns in Germany and England, choosing these countries’ health systems because each had a wave of privatization efforts following particular market reforms: German campaigns took place during a 7-year period following the 2003 introduction of Diagnosis-Related Groups, a new pricing system that made it more difficult for public hospitals to cover their costs; by contrast, the English campaigns occurred in a 4-year period following the 2012 Health and Social Care Act, which restructured the competitive tendering of services to increase private-sector involvement and competition. We understand ‘privatization’ as a change in the ownership of services from public to private ownership (Krachler and Greer, 2015). In Germany, major cases are ‘material privatization’: the transfer of state and municipal hospitals to for-profit hospital chains. In England, major cases are ‘functional privatization’ where competitive tendering entails a transfer of activity to private companies.
Interviewees by country and role.
Primarily to cross-check interview data, we gathered information from documents, like trade unions’ newsletters and the German Infodienst Krankenhäuser; and publicly available statistics, particularly, from the Government’s Contract Finder for NHS commissioning exercises, the Statistisches Bundesamt, and the PwC Transaktionsmonitor Gesundheitswesen.
Regarding data analysis, we examined ‘convergent evidence’ (Yin, 2003: 50) across the subunits to ascertain cross-national trends. First, we categorized each subunit’s outcome as successful (halting privatization plans), partially successful (delayed or stalled privatization plans) or unsuccessful (implemented privatization plans), yielding a general trend of successful campaigning in England and unsuccessful in Germany with two German cases of partial success. Subsequently, we investigated explanatory factors that influenced decision-making regarding structural reforms that were situated predominantly at local and regional levels due to health system structures [state-level politicians had decision-making authority over hospital infrastructures in Germany (Greer et al., 2013b), whereas in England, this authority fell to local-level ‘clinical commissioning groups’ led by primary care physicians (Krachler and Greer, 2015) until the 2022 Health and Care Act]. To account for variations in campaign success, we sought power resources differences across subunits and between country cases, with most extant power resource types yielding little explanatory power. However, several political factors related to healthcare system structure emerged as influential when comparing the generally divergent trends across countries. Further analysis of the German cases of partial success demonstrated the importance of partisanship regarding German state governments’ ideological inclination to privatize (i.e. where state governments were left-wing, they were less inclined to privatize). In a final round of analysis, the influential differences were conceptualized as ‘political power resources’ whereby each system’s political structures interacted with union agency to either constrain, partially constrain, or facilitate union-led anti-privatization campaigns.
Findings
Anti-privatization campaigns and their outcomes.
Source: UK government contracts finder archive https://data.gov.uk/data/contracts-finder-archive/; German Hospital Register (DKV) https://www.deutsches-krankenhaus-verzeichnis.de/ (2016).
Cross-national comparison of power resources and union success in anti-privatization campaigns.
Regarding associational power, unions in both countries had membership densities above the national averages. In England, union density has been estimated at 58% (whereas overall UK union density was 29%); in Germany, ver.di membership was estimated at 23% in public hospitals and 80% of hospital physicians are Marburger Bund members (whereas overall density was 18%; Hermann and Flecker, 2013). Accordingly, British healthcare unions had an overall larger membership: Unite’s 100,000 members, UNISON’s roughly 160,000 members, the RCN’s 420,000 members, and the BMA’s 160,000 qualified doctor members surpassed the 385,000 members of ver.di’s health and care section and the Marburger Bund’s roughly 130,000 members. Additionally, unions’ spending was comparable: while UNISON spent around £29.8 million on branch organization, a union official estimated the budget for anti-privatization campaigns as in the tens of thousands of pounds and ver.di’s health section spent around €349,000 on branch organization.
There was also little difference in institutional power from healthcare-specific labour market institutions. In German healthcare, works councils and sectoral collective bargaining constituted institutional power resources for unions. Works councils, however, must act in the organization’s financial interest, and only have information and consultation rights – not co-determination rights – over questions of organizational restructuring (Greer et al., 2013b). In UK healthcare, the collectively bargained pay and competency framework ‘Agenda for Change’ has also provided trade unions with significant institutional power (Galetto et al., 2014). Different from the wider British political economy, Agenda for Change covers NHS hospital trusts and has provided unions with information and consultation rights regarding organizational restructuring (Bach and Kessler, 2012; Krachler, 2023). Furthermore, there are local, regional and national partnership forums covering the NHS in England and the devolved nations (Bacon and Samuel, 2017).
Instead of labour market supports or other types of power resources, the main difference lay in constraints on unions’ anti-privatization campaigns derived from the politics of healthcare in their respective country contexts.
German campaigns
Generally, ver.di had no problem mobilizing members and allies; campaigners were able to frame issues broadly, sustain local partnerships, and diffuse new practices between various locations. Instead of associational or other PRs, unions had few political power resources, accounting for campaign failures. This was because in German healthcare, state-level politicians had decision-making authority over hospital infrastructure planning. With financial pressures facing state and local governments due to a 2002 law that implemented diagnosis-related groups (DRGs), a form of episode-specific financing aimed at containing costs, campaigners faced Conservative and Liberal politicians who favoured privatization as the solution and had the legal backing to privatize.
German cases of failure
In all German cases of campaign failure, right-wing governments mobilized their governing authority to force privatization through, even despite large-scale mobilizations.
In implementing privatization plans, politicians often ignored large-scale, public mobilizations, that evidenced unions’ associational power, ideational power through elaborate framing and coalition power through broad, progressive coalitions. This suggests politicians did not associate electoral costs with privatization. For example, in Hamburg, the government ignored the result of a referendum in which the overwhelming majority voted against privatization. In Krefeld and Pinneberg, Conservative-led governments accelerated the privatization decision so the referendum initiatives could not conclude before the privatization. By preparing privatization in 2010, the Conservative-led government of Schleswig-Holstein violated a non-privatization clause won in a collective agreement in 2008 that would only have expired in 2015.
Unionists mobilized ideational power by framing privatization as ineffective and immoral, and formed broad coalitions with their extensive coalition power. For example, in Hamburg (our largest privatization case), ver.di embarked on a multi-faceted campaign called ‘Health is not a Commodity’ in response to the privatization initiative. This was supported by the centre-left political parties, diverse parts of civil society and the local trade union confederation, the Deutscher Gewerkschaftsbund (DGB) (DGB_Officer_Hamburg, 2004), and involved large demonstrations of workers and supporters (observation, Hamburg, 2004). After the government ignored the referendum result, the anti-privatization campaign spilled over into an effort to strengthen local direct democracy led by ver.di and Mehr Demokratie e.V. (ver.di_Officer_1_Hamburg, 2006).
Another prominent case was the privatization of the university clinics Marburg-Gießen in Hessen in 2006, the second largest hospital privatization after Hamburg, which ‘Rhön-Klinken AG’ (the parent company of ‘Helios’) later purchased for €3.03bn in 2013. Unionists formed an alliance with civil society actors called ‘Save the Clinics’. Their campaign highlighted the risks of private provision, including the closure of unprofitable hospital units, a decrease in bed numbers and longer waiting lists for surgeries.
In Krefeld and Pinneberg, ver.di also built coalitions of Social Democrats, Greens and Left politicians before the local governments quickly finalized the hospital sales.
In these four failure cases, it was the lack of political power resources – state governments that were Conservative-led, ideologically inclined towards privatization and had the legal ability to privatize despite large-scale opposition – that primarily accounted for failure.
Ideological inclination
In Hamburg, a Conservative-led coalition government – including a Liberal health senator – initiated privatization shortly after winning a local election and unseating a Social Democratic government. At Marburg-Gießen, the Conservatives governed Hessen, and in Krefeld and Pinneberg, the Conservatives were in coalition with the Liberals.
The Conservative-led governments believed that privatization would enhance hospital efficiency and thereby solve financing problems, and often emphasized expediency. For example, according to the Conservative prime minister of Hessen at the time of the Marburg-Gießen privatization: There is much to be said for the fact that private individuals are better able than the state to organize clinics on a regular basis…in a few years we…will no longer have very many hospitals that are not operated in private companies because the private sector…will undoubtedly be able to provide the same services as a public system, but with the result that they will also generate an economic surplus in the process, without any poorer services for employees and patients (Roland Koch, Hessischer Landtag, 16.Wahlperiode, 89. Sitzung, 20. Dezember, 2005, S. 6223).
Legal ability to circumvent public opposition
This ideological inclination combined with politicians’ extensive ability to force through privatization because political institutions allowed elected local and state parliaments to legally circumvent the results of referenda against privatization that unionists and campaigners organized. For example, in Hamburg, the constitutional court ruled that, because the referendum did not include a draft bill, but merely a demand for non-privatization, it was a request and therefore nonbinding. Furthermore, in any case, the parliament could revisit a referendum after a certain time specified in Land-level legislation. Indeed, in both cases of partial success, Dresden and Schleswig-Holstein, restrictions on privatization were temporary; and in Schleswig-Holstein Conservatives returned to power in 2017.
German cases of (partial) success
Not all German cases failed at disrupting privatization efforts: in Dresden, unionists contributed to preventing privatization while in Schleswig-Holstein, privatization plans were halted. In both cases, political power resources were more favourable for unions: unions negotiated with left-wing governments who were less ideologically inclined towards privatization, and instead, agreed to wage concessions to financially alleviate the hospitals.
Ideological disinclination
Social Democrats tended to oppose privatization, and Social Democrat, Green and the Left parties were usually part of anti-privatization alliances. In Schleswig-Holstein, a Social Democratic government had delayed privatization after the expiration of the anti-privatization clause, in 2015 (ver.di_Officer_2 and ver.di_Works_Councillor_2_Kiel, 2015). In Dresden, municipal hospitals were not privatized after the anti-privatization referendum ceased to be binding because the control of Dresden city council changed from right-wing parties to Social Democrats, Green, Left and Pirate party in 2014 (ver.di_Works_Councillor_1_Dresden, 2016).
In this more favourable political climate, unionists accepted wage concessions to delay or avoid privatization. In Schleswig-Holstein, 3 years prior to the first privatization attempts in 2008, employees had been sacrificing their wages for hospital restructuring. In the negotiations for another concessionary collective agreement, ver.di struck, winning a clause that prevented privatization until 2015. Partial privatization occurred with a public private partnership to finance a necessary new building and subsequent spinning-off of ancillary services to a fully-owned subsidiary (ver.di_Officer_2_Kiel, 2015; ver.di_Works_Councillor_3_Kiel, 2016).
In Dresden, ver.di successfully led a referendum against privatization in anticipation of the city government changing to left-wing parties despite the owner of the municipal hospitals aiming to access investment and ease financial deficits through privatization. Ver. di, Social Democrats and Left party initiated a local referendum and corresponding campaign, supported by the Greens and the ‘Alliance for Hospitals’ consisting of active employees and works councils of the two municipal hospitals, several grassroots initiatives, Marburger Bund and the General Staff Council of the city of Dresden (ver.di_Works_Councillor_1_Dresden, 2016). The Dresden public was particularly sensitive to privatization issues due to the sale of the municipal housing company in 2005, despite strong public protest. At that time, a disproportionately high quorum of signatures was required to arrive at a referendum vote. In 2006, however, the threshold was lowered from 15% to 5% of the population. On this basis, the alliance initiated a local referendum in 2012 over both a private legal form (a GmbH or corporatization) and privatization of the hospitals. Voters rejected both proposals based on a voter turnout as high as in municipal elections (84% of 134,000 voters; ver.di_Officer_3, ver.di_Works_Councilor_1, and Politician_1, Dresden, 2016) and the new left-wing city government respected the result, avoiding privatization.
Pandemic update
In line with our emphasis on political factors as influential, union-led campaigns – in interaction with the crises contexts (the Great Financial crisis and the pandemic) – have contributed to making privatization less of a legitimate health policy mechanism in Germany since 2007/2008, as one unionist described: The German government had, to limit the economic effects of the Lehman Brothers crisis, a program for domestic investment. And we at ver.di, among others, said that if you want to quickly initiate an effective stimulus investment program...then you have to support hospital investment because all hospitals have a lot of demand, many hospitals have ready-made plans that one can quickly implement and that are effective domestically, like construction or medical technology...and through that, the financial situation on the hospital investment front became better...that’s why the optimism around ‘privatized is more affordable, better, cheaper’…has broken down…My impression is that private hospitals in the [COVID-19] time conducted proper health services delivery, a proper crisis management…[and sharing data] to promote societal knowledge, even to say: ‘we are the good guys in Corona’ (former_ver.di_National_Officer_1_Berlin, 2022).
English campaigns
Like in Germany, English unionists faced strong financial pressures to privatize resulting from national government austerity and marketization policies, against which they staged mass mobilizations with support from the public and other campaigners, utilizing their strong associational and other power resources. In contrast to Germany, however, English unionists enjoyed several political power resources, linked to a favourable political context in the 2015 general election because of which politicians whose constituencies highly valued public healthcare provision and faced privatization proposals expected electoral costs, prompting them to support anti-privatization campaigns. Because of such political dynamics and other related reasons, commissioners predominantly decided that privatization plans were unfeasible.
Success factors in England
Like in Germany, English trade unionists found many partners willing to campaign against privatization; but unlike Germany, English politicians in whose constituencies privatization plans were proposed were perceived potential electoral costs, and private providers sometimes perceived reputational costs, both accruing from the public’s valuation of the NHS. Additionally, the lengthy – and partly ambiguous – regulatory framework allowed unionists and campaigners to contest contract awards. Together, these political dynamics converged to make privatization plans unfeasible for commissioners, prompting them to withdraw plans.
Like in Germany, unions mobilized their extensive associational and coalition power as well as ideational power through the framing of privatization plans as ineffective and immortal. Most anti-privatization campaigns involved local union branches, sometimes with support from their national offices (UNISON_National_Officer_1_London, 2015; Unite_Officer_1_Nuneaton, 2015). In Weston-super-Mare, local trade unions, politicians and NHS campaign groups collaborated to stop the private take-over and restructuring of the hospital. At George Eliot Hospital in Nuneaton, the national union sent in Unite trade unionists with experience in leading successful campaigns to work with local activist, leading various forms of collective action including local market stalls, leafletting, picketing and petitions. UNISON led their own campaign in parallel but collaboration between the two campaigns remained loose (Unite_Officer_1_Nuneaton, 2015). Other local campaigns in 2013–14 which succeeded in keeping services out of private-sector control include Bristol (mental health services), West Sussex (musculoskeletal services), Dorset (pathology), and Cambridgeshire (adult care). The largest ever commissioning exercise at the time – a 10-year contract for cancer care services in Staffordshire worth around £1.2 billion – was strongly opposed by the public, for example, through 70,000 signatures for a petition, and suspended in 2015 and cancelled in 2017. In these mobilizations, unionists and campaigners framed privatization as a threat to the NHS’s founding principles, bringing the issue into national media. To harness this high degree of politicization, trade unions established local networks of allies with civil society groups, politicians, and residents. By developing and mobilizing these networks into protest, unions were able to demonstrate broad local opposition to privatization in addition to national media attention.
While associational, ideational and coalition power resources were similar, unlike in Germany, English unions operated with extensive political power resources. Public support for the NHS – particularly the widespread view that it is a ‘national treasure’ – played a key role in making campaigns successful, predominantly by making it difficult for policymakers to depoliticize privatization proposals. As one interviewee noted, ‘It’s difficult with the NHS, it’s a cherished institution. The NHS came up above the Royal Family, the army, the BBC, parliament, in a survey’ (UNISON_National_Officer_1_London, 2015).
This high degree of politicization generated uncertainty and unwanted publicity for firms and policymakers, including the expectation of electoral costs in the upcoming general election, making decision-makers vulnerable to anti-privatization campaigns. The NHS’s politicization was amplified in the period leading up to the 2015 general elections, with interviewees expressing the fear of losing local elections, which, in turn, forced Conservative politicians to downplay support for privatization, particularly as Labour made defending the NHS its principal issue. This was especially marked in Nuneaton, a highly contested, Conservative seat. Here, Labour set up its own campaign called ‘Keep GEH part of the NHS’ because getting involved in this local issue had the potential of gaining voters in the upcoming national elections. As polling firm Ipsos Mori reported on the eve of the election: One area where the government needs to tread very carefully is health services. Fear for the future of the NHS is at the highest level we’ve measured, and the risks are very real for the government if they are seen to damage one of the UK’s most treasured institutions (Ipsos Mori, 2015).
In addition to the high politicization of healthcare, mechanisms inherent in the NHS tendering process facilitated the success of anti-privatization campaigns. In particular, as contracts were time-limited and could be terminated by either party, commissioners could more easily reverse privatization than in Germany where entire hospitals were sold off. Furthermore, commissioners also had to gain a series of approvals from other parts of the NHS (UNISON_National_Officer_1_London, 2015; Healthcare_Campaigner_1_London, 2015) that could prolong the tendering process, making it too costly for private providers to bid. For example, at Hinchingbrooke hospital, the private firm ‘Circle’ withdrew from its 10-year contract to run the hospital in early 2015 after 3 years due to its failure to sufficiently improve the hospital’s financial situation or quality indicators. This set a precedent for other franchising efforts like in Weston-super-Mare: ‘[I]t was becoming clear that Hinchingbrooke wasn’t doing very well. That’s another thing that slowed [privatization]’ (UNISON_Officer_1_Weston-super-Mare, 2015). Another example is the out-of-hours GP contract in Camden and Islington services held by ‘Care UK’ which, in 2016, was not renewed, and instead awarded to a not-for-profit GP-led consortium. In this case, local Keep Our NHS Public activists had campaigned against private-sector involvement in primary care since 2009 and were heavily involved in CCG meetings to pressure decision-makers not to renew the contract.
A final important political characteristic of the English healthcare field was that the 2012 Health and Social Care Act was ambiguous in terms of the conditions under which commissioners were legally obligated to competitively tender services. As a result, trade union staff used their knowledge of the new regulation to contest the commissioning process. For example, they produced documents for branches to make guidance and legislation more manageable and easier to understand, outlining the commissioning process and helping them challenge privatization decisions and processes: ‘There was a myth that everything had to be put out to tender, when this was not the case. [Our] document was meant to explain what the law is’ (UNISON_National_Officer_2_London, 2016). These process issues combined with the fact that, as our 2013 management and policy interviewees often emphasized, contracts were often publicly visible and could lead to negative reputational costs for private providers, culminating in failed commissioning attempts aimed at privatization, or defaulting to public providers.
Pandemic update
Like in Germany, English legislators performed a change in health policy direction in response to the pandemic as well as due to campaigning success through the 2022 Health and Care Act that aims to integrate health and social services, moving away from 2010s central government marketization and privatization policies: We had the five year forward view from NHS England [in 2014]…UNISON’s view was that actually, that was quite helpful because it very much emphasised the importance of integration over competition and it began the lengthy process of officially unravelling the [2012] Lansley Act…[the unravelling has] just finished, last week, with the Health and Social Care Act…[Moving away from privatization attempts is due to] a bit of both [i.e., influence of campaigns and changing health policy]…and the pandemic has proven there is still a lot of love for the NHS as this publicly owned, publicly delivered organisation…we did run a lot of quite high profile, successful campaigns after the [2012] Lansley Act went through…where we overturned various different attempts at privatisation…as a result, that model collapsed (UNISON_National_Officer_3_London, 2022).
Discussion and conclusion
This article explored the role of institutional and other power resources in influencing the success of unions’ anti-privatization campaigns in German and English healthcare. Different from a traditional national models approach, we found that unions were more successful in England than in Germany, despite similar associational, ideational, coalition and institutional power resources derived labour market institutions. We explained this puzzle by comparing how the politics of healthcare in each country constrained, partially constrained or enabled unions’ anti-privatization campaigns.
In Germany, the healthcare system is more fragmented. The success of anti-privatization campaigns depended on local and regional level politicians’ ideological inclination and their institutionally embedded abilities to privatize without perceiving negative consequences and despite public opposition. Campaign failures occurred where politicians were of a right-wing political orientation and did not fear electoral costs associated with privatization, instead viewing it as a ready solution for alleviating public budgets; additionally, they had legal rights to do so because national funding arrangements in German healthcare meant that regional and local politicians were responsible for healthcare infrastructure funding and courts ruled that circumventing referenda was legal. We found two cases of (partial) success in Germany in which local/regional governments were not ideologically inclined to privatize and instead, wage concessions were agreed to gain efficiencies. The privatization wave in Germany subsided with the financial crisis and a package of financial support from the Federal government to hospitals demanded by unions, suggesting a somewhat changed politics of healthcare since then.
By contrast, in England’s centralized NHS, campaigns were successful because several political factors converged to make the privatization decision unfeasible/undesirable for commissioners. In the context of the 2015 general election and based on the NHS’s general, high visibility and politicization in national media and politics, politicians feared electoral costs arising from privatization plans in their constituencies, prompting them to support anti-privatization campaigns. Additionally, ambiguities in the statutory framework of commissioning created opportunities for campaigners to contest privatization: rather than politicians having the power to arrange sell-offs, commissioners separate from government decided to which type of organization to award contracts in a regulatory framework of legal ambiguity around the question of when a service is legally required to be competitively tendered. Furthermore, the NHS’s politicization could also be associated with reputational costs for private providers, leading them to withdraw from competitive tenders. After the pandemic, health policy turned against privatization, culminating in the upending of competitive tendering in England.
To the study of power resources (Arnholtz and Refslund, 2024), our article has contributed a novel form of institutional power resource: ‘political power resources’ which refer to the extent to which unions can use the political structure of a given field to achieve their objectives. The political power resources afforded by a field’s political structure differ from the predominant understanding of institutional power resources as derived from labour market institutions like labour protections, collective bargaining institutions, or co-determination rights (Bernaciak and Trif, 2023; Doellgast, 2008; Kahancová and Martišková, 2023; Kahancová and Szabó, 2015; Rigby and García Calavia, 2018): while still rooted in shared norms and rules structuring the interests of actors in the field, and in this sense a type of institutional power resource, political power resources do not rely on labour market institutions. Instead, they depend on the pressure that unions can exert on policymakers with decision-making authority regarding structural reforms, like politicians and commissioners, by virtue of how the field’s political structure converges to make policymakers’ perceptions of the undesirable consequences related to privatization proposals that union campaigns claim viable. Whether or not decision-makers are moved in favour of union campaigning therefore depends on the field’s various political characteristics like legal powers to bypass campaigning efforts (like in Germany where local referenda could legally be circumvented) and the level of media and other attention that the public puts on the issue (particularly pronounced in the English NHS).
Furthermore, our comparison of unions that enjoyed similar, other power resources – like similar institutional PRs through labour market supports, similar associational power through organizational resources, among others – demonstrated that political power resources are a distinct, influential form of institutional power resource. It is also distinct from ideational power resources (McLaughlin and Wright, 2024). While ideation could account for why a field’s political characteristics are shaped in particular ways, it is these characteristics themselves that determine whether they function as a political power resource for unions.
Moreover, because political power resources depend primarily on convincing decision-makers, they potentially allow unions to bypass employers while labour market institutions depend on cooperation and agreement with employers, especially in healthcare where responsibilities for structural reforms can lie entirely with political decision-makers or with other non-employer entities like commissioners. This is advantageous because employers have faced considerable pressure to drive down working conditions since the financial crisis (Bach and Bordogna, 2013; Gumbrell-McCormick and Hyman, 2013; Mori, 2017), including in healthcare (Galetto et al., 2014; Kahancová and Szabó, 2015; Krachler and Greer, 2015).
Our article also contributes to comparative ER more generally by highlighting the importance of unions’ extended role in shaping product/service markets (Brandl, 2023; Meardi and Tassinari, 2022). Building on insights from literature examining how ER actors respond to reforms that they receive as ‘given’ (Galetto et al., 2014; Kahancová and Szabó, 2015), our findings confirm this literature’s emphasis on the importance of power struggles for ER outcomes. Advancing this literature, we demonstrated that an extended role beyond these labour market functions depends on a field’s political structure and whether these constrain, partially constrain, or enable union campaigns, exemplified by the enabling political structures of the English healthcare system as opposed to the pre-crisis, German system’s. While our findings also confirmed that the pandemic was a particularly enabling context for unions (Brandl, 2023; Meardi and Tassinari, 2022), the dependence on political empowerment suggests that the pursuit of an extended role for unions likely varies by field structure, and at sector-level (Bechter et al., 2012).
A major implication of our article is that in turbulent economic and political contexts, campaigners’ aim of maintaining hospitals’ capacity to provide a universal service through anti-privatization campaigns is vital to public health – and yet, also dependent on the broader structuring of the politics of healthcare. For unions and other campaigning organizations, this means that they should consider whether the field’s political structure empowers them to shape the field through campaigns. Where these political power resources are absent, unions will likely be less successful at intervening in goods/services markets and should instead focus on intervening in the labour market, for example, by enhancing associational power using organizing tactics.
Regarding limitations, while our case selection and empirical setting was suitable for our purposes of ensuring ‘analytic generalizability’, and we analysed multiple cases (two country cases comprised of 14 sub-units), future research could investigate the relevance of political power resources for smaller, less publicly visible privatization initiatives and use quantitative methods for greater sample size and improved external generalizability.
Beyond healthcare, marketization and privatization are problems faced by workers, citizens, and unions in many other industry contexts. Future research could examine anti-privatization campaigns in energy, housing, transportation, water, and social services. Given the well-known problems generated by decades of privatization, political power resources may also be useful for understanding the reversal of privatization.
Moreover, unions generally enjoyed similar power resources other than political ones. Future research could investigate whether political power resources could compensate for the lack of other resources, for example, by comparing sectors that have differing institutional power resources from labour market supports.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.