Background

The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England.

Methods

For this observational study, we used a novel database composed of parsable procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674, value >£25 000, total value £204·1 billion), across 173 clinical commissioning groups (CCGs; regional health boards) in England. Data were compiled from 12 709 heterogenous expenditure files primarily scraped from commissioner websites with supplier names matched to registers identifying them as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. We used multivariate longitudinal regression models with fixed effects at the CCG level to analyse the association of for-profit outsourcing on treatable mortality rates in the following year. We used the average marginal effects to estimate total additional deaths attributable to changes in for-profit outsourcing. We provided alternative model specifications to test the robustness of our findings, match on background characteristics, examine the potential impact of measurement error, and adjust for possible confounding factors such as population demographics, total CCG expenditure, and local authority expenditure.

Findings

We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% (95% CI 0·22–0·55; p=0·0016) or 0·29 (95% CI 0·09–0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153–961) treatable deaths across the 173 CCGs.

Interpretation

The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013–20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.

Funding

Wellcome Trust.

中文翻译：

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2013-20 年英格兰将医疗保健服务外包给私营部门和可治疗死亡率：NHS 私有化的观察性研究

 背景

将医疗服务外包给营利性提供商的效果存在争议，一些人认为引入此类提供商将通过额外的竞争来提高绩效，而另一些人则担心这将导致成本削减和患者的预后较差。我们的目的是根据 2012 年《健康和社会保健法案》，通过实证评估向私人医疗服务提供者外包支出对英格兰可治疗死亡率和医疗保健服务质量的影响来审视这场争论。

 方法

在这项观察性研究中，我们使用了一个新颖的数据库，该数据库由 2013 年 4 月 1 日至 2020 年 2 月 29 日之间的可解析采购合同组成（n=645 674，价值 > 25 000 英镑，总价值 204·10 亿英镑），涵盖 173 个临床项目英格兰的委托团体（CCG；地区卫生委员会）。数据是根据主要从专员网站上抓取的 12,709 个异质支出文件编制的，其中供应商名称与登记册相匹配，将其标识为国家医疗服务 (NHS) 组织、营利性公司或慈善机构。我们补充了这些数据，补充了当地因可通过医疗干预治疗的原因造成的死亡率，表明了医疗保健服务的质量。我们使用 CCG 水平上具有固定效应的多元纵向回归模型来分析营利性外包与下一年可治疗死亡率的关联。我们使用平均边际效应来估计因营利性外包变化而导致的额外死亡总数。我们提供了替代模型规范来测试我们研究结果的稳健性，匹配背景特征，检查测量误差的潜在影响，并调整可能的混杂因素，例如人口统计、CCG 总支出和地方当局支出。

 发现

我们发现，向私营营利部门的外包每年增加 1 个百分点，可治疗死亡率每年增加 0·38%（95% CI 0·22–0·55；p=0·0016）或次年每 10 万人中有 0·29 人死亡（95% CI 0·09–0·49；p=0·0041）。这一发现对于匹配背景特征、调整可能的混杂因素以及数据集中的测量误差是稳健的。自 2014 年以来营利性外包的变化与 173 个 CCG 中额外的 557 例（95% CI 153-961）可治疗死亡相关。

 解释

通过将服务外包给营利性公司，英格兰 NHS 的私有化在 2013-20 年间不断加强。私营部门外包导致可治疗死亡率显着上升，这可能是由于医疗保健服务质量下降造成的。

 资金

 惠康信托。