Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I note that the title of this article appears to link for-profit providers with higher rates of preventable death but I would counsel readers from making that conclusion.
In fact the authors of the featured article (ref 1) were unable to make that link:
"There are two primary ways that outsourcing to for-profit providers might lead to increased mortality. First, the private providers receiving NHS contracts could simply be delivering worse quality care, resulting in more health complications and deaths. For-profit providers tend to cut costs more than public providers; this can be through staff numbers and qualification levels or adherence to guidelines for correct medical processes. However, recent evidence finds no substantial difference in the rate of deaths from surgeries in private and public hospitals in England, even if selection effects make this estimation difficult. NHS surgeries might be delivered under more stringent conditions by for-profit companies than by NHS providers; however, differences in health outcomes are yet to be observed for those treated by NHS providers versus those treated by for-profit providers.
"A second reason for the increased mortality rates could be that outsourcing leads to intensified pressure across the whole health system. Outsourcing can increase pressure on the wider system if profitable patients and services are cream-skimmed (ie, preferentially selected) by for-profit providers, creating a concentration of difficult treatments in public providers, as was witnessed in the NHS outsourcing to private hospitals during the 2000s. Similarly, increased competition for contracts could result in health-care providers prioritising easily quantified outcomes such as waiting times at the expense of quality of care, resulting in higher patient mortality, as was identified in the NHS after the pro-market reforms during the 1990s. The fact that we focused on a measure of health-care service performance and found no association between mortality and outsourcing when using a measure of mortality from causes that are treated by public health interventions suggests the overarching explanation for the increased mortality rates might be an aggregate decline in the quality of care. At the same time, more research is needed to unpack the precise mechanisms of worsening care in England since 2013, including an assessment of how private providers contribute to quality and safety data and systems of accountability. Another future avenue of research is the impact of outsourcing on health inequalities at the neighbourhood level, and the qualitative impact of access to health care."
Hence the link between outsourcing to private providers to rise in treatable deaths does not prove for-profit providers are delivering poor health service. The trend for reversal of preventable deaths actually occurred prior to the Health and Social Care Act implemented in 2012, and we have to be careful not to misattribute these findings to private providers, who delivered services outside the NHS system then already facing a looming staffing and capacity crisis.
Beware of making private providers the scapegoats of evolving trends of poor healthcare outcomes which started before their involvement.
No proof that for-profit providers are actually delivering worse quality care that resulted in more preventable deaths
Dear Editors
I note that the title of this article appears to link for-profit providers with higher rates of preventable death but I would counsel readers from making that conclusion.
In fact the authors of the featured article (ref 1) were unable to make that link:
"There are two primary ways that outsourcing to for-profit providers might lead to increased mortality. First, the private providers receiving NHS contracts could simply be delivering worse quality care, resulting in more health complications and deaths. For-profit providers tend to cut costs more than public providers; this can be through staff numbers and qualification levels or adherence to guidelines for correct medical processes. However, recent evidence finds no substantial difference in the rate of deaths from surgeries in private and public hospitals in England, even if selection effects make this estimation difficult. NHS surgeries might be delivered under more stringent conditions by for-profit companies than by NHS providers; however, differences in health outcomes are yet to be observed for those treated by NHS providers versus those treated by for-profit providers.
"A second reason for the increased mortality rates could be that outsourcing leads to intensified pressure across the whole health system. Outsourcing can increase pressure on the wider system if profitable patients and services are cream-skimmed (ie, preferentially selected) by for-profit providers, creating a concentration of difficult treatments in public providers, as was witnessed in the NHS outsourcing to private hospitals during the 2000s. Similarly, increased competition for contracts could result in health-care providers prioritising easily quantified outcomes such as waiting times at the expense of quality of care, resulting in higher patient mortality, as was identified in the NHS after the pro-market reforms during the 1990s. The fact that we focused on a measure of health-care service performance and found no association between mortality and outsourcing when using a measure of mortality from causes that are treated by public health interventions suggests the overarching explanation for the increased mortality rates might be an aggregate decline in the quality of care. At the same time, more research is needed to unpack the precise mechanisms of worsening care in England since 2013, including an assessment of how private providers contribute to quality and safety data and systems of accountability. Another future avenue of research is the impact of outsourcing on health inequalities at the neighbourhood level, and the qualitative impact of access to health care."
Hence the link between outsourcing to private providers to rise in treatable deaths does not prove for-profit providers are delivering poor health service. The trend for reversal of preventable deaths actually occurred prior to the Health and Social Care Act implemented in 2012, and we have to be careful not to misattribute these findings to private providers, who delivered services outside the NHS system then already facing a looming staffing and capacity crisis.
Beware of making private providers the scapegoats of evolving trends of poor healthcare outcomes which started before their involvement.
Reference
1. https://doi.org/10.1016/S2468-2667(22)00133-5
Competing interests: No competing interests