Privatisation associated with decline in quality of healthcare

The first comprehensive analysis of the effects of the Health and Social Care Act 2012 – which encouraged greater outsourcing of NHS services – reveals increased privatisation has led to a decline in the quality of patient care.

Outsourcing NHS services to the private sector is associated with reduced quality of patient care and increased rates of deaths from treatable causes, in the analysis published in The Lancet Public Health journal.

Outsourcing of NHS services in England to for-profit companies increased steadily between 2013 and 2020, rising to over 6% of total expenditure for regional health boards.

Increased privatisation was associated with higher rates of treatable mortality, with changes to outsourcing potentially linked to an extra 557 avoidable deaths in England during the study period.

The findings suggest caution around further outsourcing of NHS services in future, given the potential impact on quality of patient care.

‘The unparalleled data utilised in this study enabled us to conduct the first rigorous analysis of one the most controversial health care reforms in England’s recent history. While some have argued the Health and Social Care Act would improve the performance of health services by increasing competition, our findings add merit to long-standing concerns it could instead lead to cost-cutting and poorer health outcomes,’ said study author Benjamin Goodair of the University of Oxford.

The authors analysed a new data set showing how much each regional health board spent on outsourcing between 2013 and 2020.

Changes to the quality of health services were determined using a statistical analysis to investigate associations between outsourcing and treatable mortality – deaths considered avoidable with timely, effective healthcare.

Further analysis looked for any association between outsourcing and preventable mortality – deaths mainly avoidable with effective public health, not medical interventions – which is not regarded as a measure of healthcare quality.

The researchers analysed data on over £204bn of expenditure – comprised of more than 645,000 individual payments – for 173 of England’s 191 regional health boards (as of 2019) between 2013 and 2020.

In total, £11.5bn was spent outsourcing health services to the private sector over the period, with the amount varying considerably by individual health board. The largest increases in outsourcing spend were on business and IT support, with steady increases in spending on healthcare businesses, social work, and transport companies.

The statistical analysis showed that an annual increase in outsource spending of 1% is associated with a rise in treatable mortality of 0.38% (0.29 deaths per 100,000 population) the following year.

There was no association between outsourcing and rates of preventable mortality. This further suggests that the relationship between outsourcing and treatable deaths is linked to quality of care, rather than a consequence of general trends in health outcomes in the population.

Study author Dr Aaron Reeves, of the University of Oxford, added: ‘These results clearly have implications for the NHS privatisation debate, suggesting that increased outsourcing to the private sector could lead to a decline in the quality of care provided to patients. While more research is needed to determine the precise causes of the declining quality of healthcare in England, our findings suggest that further increases in NHS privatisation would be a mistake.

‘The findings of this research are timely as the way England’s health boards are organised is set to be overhauled. This creates a key moment where the role of the private sector within the NHS must be closely scrutinised.’

Photo by Artur Tumasjan