• Research that shows better outcomes for private hospitals is missing the key depth to be definitive.
  • The data shows that NHS patients treated in private hospitals are wealthier, older, fitter and more are white.

Healthcare Markets magazine was predictably delighted to largely reprint a recent press release from Birmingham University on research showing that NHS operations delivered in private hospitals appear to involve “shorter hospital stays and fewer readmissions than in NHS hospitals.”

Especially congenial to the private sector magazine are the assurances from Birmingham Uni’s Professor Richard Lilford, that despite “plausible concerns” regarding the safety of elective surgery in the independent sector: 

“Taken in the round, our findings provide a measure of reassurance that independent sector healthcare providers [IHSPs] are providing an acceptable service.”

However, keeping the door open for further research projects funded by the  National Institute for Health Research (NIHR) the Prof went on to note that:

“our results stop short of total reassurance, and ongoing scrutiny of a richer set of outcomes and further investigation of practice is required in both the NHS and the independent sector.”

Indeed the initial project may have sifted through 3.5million episodes of care between 2006 and 2019, but it asked very few questions, and made no attempt to explain or evaluate the results they found, even though the clues are in plain sight.

It finds length of stay in hospital for all 18 common surgical procedures analysed was longer for patients treated in NHS hospitals than those treated in the private sector. 

Why should this be the case? Is it not certainly linked to the fact that, especially since the launch of “independent sector treatment centres” in the mid-2000s, with specific protocols defining which patients were and were not appropriate, patients have always been screened to ensure the NHS sent only the least complicated cases, and those with support at home, to private hospitals? 

The study notes that while “Reimbursement levels are the same irrespective of which type of organisation provides treatment,” patients treated in the private hospitals tend to be whiter, healthier and wealthier [and we might add less expensive] than the NHS casemix. They had:

“fewer underlying conditions; lived in more affluent areas; and tended to be White (or had no ethnicity recorded) than those treated in NHS hospitals.”

In other words the private sector has continued to cherry-pick the easiest patients to treat and discharge, leaving the NHS to cope with a much more complex and demanding caseload. 

According to the report data 3.2m of the operations were in 734 NHS hospital sites and 468,000 operations in 274 private hospitals. Each relatively much smaller private hospital therefore averaged just 1,708 patients over the 13-year period compared with 4,364 per NHS site. However, while the private hospital sites involved are listed (some of them more than once if they changed ownership), no detail is given on how as many as 734 NHS units were identified, compared with around 170 acute trusts. 

More important, there is no comparison of staffing levels to allow any assessment of the amount of post-operative support given to patients.

The report states that nearly 40% of patients treated in independent sector hospitals were discharged on the same day after a total hip replacement, “compared with less than 5% of patients treated in NHS hospitals, who stayed an average of 5 days.” 

With no further information on the circumstances of these patients and the availability of community-based services to support them on discharge from hospital, it’s impossible to draw any conclusions from this – other than that wealthier fitter people are more likely to be mobilised more quickly, and to have reliable support in place at home, than poorer, less healthy ones.

Moreover the study only tacitly admits that when things go wrong, the NHS has to carry the can – whether or not the patient had their operation in a private or NHS hospital. It states blandly that “patients in independent sector hospitals were more likely to be transferred to another hospital as an emergency.” But the press release cited by Healthcare Markets does not clarify that all  emergency care is provided by the NHS, even though the full report does admit:

“Many ISHPs lack the full range of services, including intensive care, required for management of an emergency case. Thus, given an emergency, a patient in an ISHP is more likely to be transferred than an equivalent patient in the NHS who is already likely to be in the institution of last resort.”

Not the solution

If these missing questions are asked it becomes far clearer that far from being part of the solution to the current growing NHS crisis, the private sector is part of the problem. Its very existence and periods of growth have depended upon gaps and weaknesses in the NHS, and its expansion as supposedly “additional” beds and capacity can only take place at the expense of draining the available limited pool of NHS-trained staff.

Even if the whole of the bed capacity of acute sector private hospitals were to be somehow procured ,it only amounts to 8,000 beds – just 8% of the latest, reduced total of NHS acute beds in England, and less than half of the 16,000 acute beds that compared with pre-pandemic in 2019 are either still standing empty or filled with Covid patients on the latest figures.

If the NHS could access the necessary capital and staff, and was focused on reopening the unused beds, it would be far more productive to expand capacity that way than to divert staff from already busy teams in the main hospitals to conduct operations some miles away in small-scale private hospitals.

In practice all 8,000 private acute beds will never be available to the NHS unless the private hospitals are nationalised. The companies that own them can make so much more money from privately insured and self-pay patients driven to desperation by NHS waiting lists, they will never see full dependence on the treating NHS patients at tariff prices as a profitable option.

As for the Birmingham Uni research? The best that can be said is “could do better”.

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