Intended for healthcare professionals

Views And Reviews No Holds Barred

Margaret McCartney: Do we want an NHS that depends on outsourcing?

BMJ 2018; 360 doi: (Published 19 February 2018) Cite this as: BMJ 2018;360:k670
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

Carillion, the outsourcing company that provided the NHS with cleaners, porters, and catering, has hit the buffers. The only people surprised by this are those who haven’t been paying attention.

Outsourcing as a principle has been beloved of governments of red and blue hues over the past couple of decades. Under this model, companies are not directly contracted to do certain work: instead, a large company contracts smaller companies to do it.

As outsourcing has become normal the debate on what “privatisation” of the NHS amounts to, or what it would look like, is magnified. What does it matter who provides a service, as long as it’s under the banner of the NHS and adheres to the contract? We don’t expect (or want) the NHS to make paper, build ambulances, or manufacture CT scanners: private involvement in the NHS has always happened, and outsourcing is not new. This logic has underpinned the recent history of NHS contracting.

As outsourcing has become normal the debate on what “privatisation” of the NHS amounts to, or what it would look like, is magnified

The annual value of outsourcing work now offered under tender from the NHS is £5.9bn.1 Circle was awarded a contract to run Hinchingbrooke Health Care NHS Trust in 2010, only to hand back its contract to the NHS in 2015 with requests for government bailouts.2

In 2015 Capita took on a £1bn, seven year contract for “back office” functions in England.3 Repeated disruptions followed, such as GP trainees’ salaries going missing,4 syringes not being supplied,5 GPs being unable to get onto the performers list, and notes going missing.6 In the wake of these, the National Audit Office has announced an investigation into the Capita deal.7

And recall that Atos—which prematurely ended its contract supplying medicals to the Department for Work and Pensions because of “quality concerns,”—subcontracted work to other companies, as well as back to the NHS.8

Ah, some might counter: but GPs are also private businesses. That may be so, but I don’t compete with other practices in my area in the way outsourced service providers compete with one another. But the GPs’ NHS contract does allow for competition between practices, and some new kinds of general practice—especially those operating online—increasingly exploit this to compete for patients who are likely to use fewer resources.

It’s all about efficiencies, say the management consultants who have recommended the wider use of outsourcing. So, if harmless efficiency is possible, why can’t the NHS do it and keep the savings for itself? And if better efficiency isn’t possible, and striving for it leads to active harms, surely it’s better for us to ensure that avoidable damage isn’t done. Devolving responsibility to companies that are immune to freedom of information requests, and frequently bailed out by the taxpayer, is not the way to do it.



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