Privatisation of the NHS has been found to correspond to a decline in care quality and “significantly” increased deaths from treatable causes, according to a study from researchers at the University of Oxford.

The study – Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: an observational study of NHS privatisation – published in The Lancet Public Health analysed data from Clinical Commissioning Groups (CCGs) in England and the researchers concluded that:

“increased for-profit outsourcing from clinical commissioning groups [CCGs] in England might have adversely affected the quality of care delivered to patients and resulted in increased mortality rates”.

It is the first study of its kind to look at the impact of the acceleration of privatisation brought about by Andrew Lansley’s reforms in 2012; policies that forced local commissioning bodies to put contracts out to tender leading to an influx of private companies running NHS services.

It has implications for today, as although the recent health and care bill reversed some of the 2012 rules on commissioning, the government is still actively encouraging the use of the private sector to address the NHS waiting list that stands at a record 6.5 million people due to a legacy of over a decade of underfunding and the pandemic. This study now casts doubt on the safety of this approach for NHS patients.

An analysis of payments to private companies by 173 CCGs across England found that despite many commentators claiming otherwise, outsourcing from England’s NHS commissioners to for-profit companies steadily increased in the period, rising to more than 6% of total commissioner spending in England in 2020, although there were considerable differences between CCGs. A total of £11·5 billion of outsourced contracts were received by for-profit companies between 2013 and 2020.

An analysis of the relationship between outsourcing and mortality rates found that an annual increase in outsource spending of 1% is associated with a rise in treatable mortality the following year of 0.38%, or 0.29 deaths per 100,000 people. A total of 557 additional deaths between 2014 and 2020 might be attributed to the rise in outsourcing, according to the researchers. These deaths were termed treatable deaths as they are considered to be avoidable with timely, effective healthcare. 

A second analysis found no significant association between outsourcing and preventable mortality rates – those deaths avoidable with effective public health instead of medical interventions. Leading the authors to conclude that the relationship between outsourcing and treatable mortality found in the first analysis is not a product of general health outcomes in the population but is more directly associated with the quality of healthcare services.

For many years those championing marketisation of the NHS, including successive Conservative governments, have claimed that competition and management autonomy would improve efficiency and performance of the NHS. However, these results suggest that such outsourcing of healthcare services has instead increased deaths among patients.

The reasons for the increase in mortality is still under discussion. Is it that the private providers are delivering worse quality care, for example, due to cutting costs, in order to bump up profits, either by reducing staff numbers or the levels of various qualified staff, or is there reduced adherence to guidelines? 

Another possibility put forward by the authors is that outsourcing leads to intensified pressure across the whole health system. If profitable patients and services are cream-skimmed (i.e, the uncomplicated cases and services are preferentially selected) by for-profit providers, it creates a concentration of difficult treatments in public providers, but without any increased resources to tackle them. 

Similarly, increased competition for contracts could result in private healthcare providers prioritising easily quantified outcomes such as waiting times at the expense of quality of care, resulting in higher patient mortality.

The authors acknowledge that there are limitations to the study, and more research is needed to determine the precise causes of the decline in healthcare quality in England, but they note that implication of their findings is that: 

“further privatisation of the NHS might lead to worse population health outcomes.”

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