A decline in the quality and safety of care

One of the most serious affects of outsourcing in the NHS that has been observed is a decline in the quality and safety of care. Quality and safety are linked and have been found to decline for a number of reasons.

In June 2022, a study was published in The Lancet Public Health that stated that the privatisation of NHS care has corresponded with a decline in quality and “significantly increased” rates of death from treatable causes. The study looked at the time period from 2013 to 2020. Acceleration of privatisation began in 2012 after the introduction of the Health & Care Act 2012 by the health secretary, Andrew Lansley, in the Tory-Lib Dem coalition government, which forced local health bodies to put contracts for services out to tender.

The analysis by researchers at the University of Oxford states that “The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased [after 2012],” and “Private-sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of healthcare services.”

Researchers analysed data showing how much 173 CCGs in England spent on outsourcing between 2013 and 2020, which grew from 3.9% to more than 6.4%. In total, £11.5bn was handed to private companies over the period, although the amount varied considerably between CCGs.

The analysis shows that an annual increase in outsource spending of 1% is associated with a rise in treatable mortality of 0.38% – or 0.29 deaths per 100,000 people – the following year. The researchers claim that 557 additional deaths between 2014 and 2020 might be attributed to the rise in outsourcing.

The authors noted that their findings “suggest that further privatisation of the NHS might lead to worse population health outcomes.”

This was the first study of its kind. Although the study could not reach any hard and fast conclusions as to why quality declined, the authors suggested two possibilities. First, the private companies might be “delivering worse-quality care” which could be due to lower level of staff overall or levels of qualified staff, or lack of adherence to guidelines “resulting in more health complications and deaths”, or secondly, because greater competition for contracts may result in for-profit providers prioritising shorter waiting times “at the expense of quality of care”.

Benjamin Goodair, study lead at the University of Oxford said “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 longstanding concerns it could instead lead to cost-cutting and poorer health outcomes.”

What the study does not mention as factors in a decline in quality of care associated with privatisation are the impact of the sudden exit from a contract of a private company, which has happened a number of times (see Financial Insecurity). This leaves patients without continuity of care or with longer waiting times, and the psychological effects of uncertainty surrounding their treatment plan.

GP surgeries

A decline in quality has been associated with the outsourcing of GP contracts to private companies. The most recent example is of the Sutherland Lodge practice in Chelmsford, Essex, which was taken over by Virgin (now HCRG Care) in July 2016 after the previous partners handed back their contracts following £400,000 funding cuts to their contract. Prior to the takeover, the practice was rated outstanding, but in May 2018 the Care Quality Commission (CQC) rated the surgery inadequate overall. The rating is based on an inspection carried out in December 2017 just 18 months after Virgin Care took over the practice. Virgin Care also received more money for the contract than the previous GPs.

Under Virgin Care the CQC rated Sutherland Lodge inadequate on four of the five key measures – the safe, effective, responsive and well-led categories – and rated it “requires improvement” in the “caring” category. The practice has been placed in special measures and if improvements are not made within six months Virgin Care could be stripped of the 10-year Alternative Provider Medical Services (APMS) contract it was awarded to run Sutherland Lodge.

There are also concerns over the way Virgin runs another GP practice in Essex; in October 2017 Nicholas Challen made an official complaint to NHS England about the treatment of his father prior to his death. He told the local newspaper that in his view “Virgin are running the surgery as a standalone profit centre, and cutting corners to make the numbers work rather than a public service, fit for purpose.” In February 2014, the CQC criticised Virgin Care over its use of non-medically trained receptionists to assess patients in its Croydon Urgent Care centre. CQC inspectors found the centre was in breach of four basic standards of care.

In April 2015, two surveys were published which indicated that private providers deliver poorer GP and out-of-hours GP services.  Researchers at Imperial College London found that private sector and other alternative providers of GP services to the NHS do not do as well as traditional GP practices.

The research found that these providers perform worse than typical surgeries on 15 of 17 key indicators – such as patient satisfaction, diabetes control and keeping patients out of hospital. In the second study, researchers at the University of Exeter Medical School, found that private providers of out-of-hours GP services deliver poorer care than NHS alternatives. The findings were based on 900,000 responses to the 2012/13 GP Patient Survey: NHS providers scored highest on timeliness, patient confidence in doctors, and overall care experience.

Mental Health Services

This sector has seen a number of scandals surrounding safety breaches in non-NHS facilities taking NHS patients. It is also a sector where it is evident that making a profit is paramount to the detriment of the patients’ care and safety.

The leading private companies in this area – Huntercombe, Cygnet Healthcare, The Priory and Elysium Health – all run hospitals and services that have had damming reports by the CQC. There have been so many incidents, wards closed, hospitals rated “inadequate”  or put in special measures that it would be impossible to include them all here, but more details of the failure in care standards can be found on the Contract Failures in Mental Health services page and on company overview pages.

In September 2019 the CQC published a report on residential mental health, noting that it had found 28 mental health units run by private companies to be “inadequate” in the past three years.  The Royal College of Psychiatrists was so concerned about the poor standards of care that it wrote to the secretary of state urging him to commission a public inquiry led by a high court judge.

For several years now there have been regular reports from whistle-blowers and the CQC of appalling quality of care at these private hospitals. The past two years have seen a number of hospitals run by private companies castigated by the CQC, particularly in the area of CAMHS. The two leading companies, The Priory and Cygnet Healthcare, have both had to close wards as a result of damning CQC reports and St Andrews Healthcare the leading not-for-profit in the sector has had severe limitations put on its services due to CQC reports.

But despite numerous serious incidents, including suicides, bullying and abuse, the NHS is so short of capacity for mental health patients, that it continues to use these private companies.

In November 2018, The Times published a damning article exposing the companies and charities that make millions by providing substandard mental health services to NHS patients. The article included one case where the directors of a psychiatric hospital that was found to provide substandard care by the CQC, had paid almost £25 million into a secretive trust in Belize. The article noted that the company had received £26.3 million for services over 18 months in 2016-17 from NHS contracts.

Another case highlighted by The Times investigation was the charity St Andrews Healthcare which paid its chief executive, Gil Baldwin, £496,000 before he left in 2017, and 76 employees salaries of more than £100,000. The charity’s facilities included a private hospital where a 17-year-old girl was locked in a cell-like room with only a mattress and chair and passed meals through a hatch in the door. Three psychiatric services run by the charity, and its overall services, had been judged in need of improvement by the CQC. The company’s facility in Mansfield in Nottinghamshire was given an ‘inadequate’ rating in February 2019 and placed in special measures.

Hospitals run by the Huntercombe Group have received particularly critical reports after inspections by the CQC. In 2016, its hospital in Stafford was placed in special measures and told to urgently improve in 24 areas. In September 2017, Watcombe Hall, was closed indefinitely after the local NHS hospital raised concerns about the number of young patients being admitted from the unit suffering from malnutrition and dehydration. In December 2018, an inspection by the CQC of the company’s hospital in Norwich found serious concerns. The CQC took immediate action to protect those using the service, including enforcement action to remove the registration for the hospital. The Huntercombe Group then closed the service and the children and adolescents had to be found places elsewhere.

One of the largest private providers of mental health services to the NHS, The Priory Group, consisting of The Priory and Partnerships in Care, has hit the headlines several times for its involvement in patient deaths. These include in 2012 14 year old Amy El-Keria, who died at Ticehurst House in East Sussex, in 2014 17-year-old Sara Green, who died in the Priory Royal in Cheadle, and in March 2016, the Priory and Solent NHS Trust admitted liability for the death of 15-year-old George Werb, who had been a patient at the Priory Hospital Southampton.

More recently in February 2019, the Priory’s hospital for children with learning disabilities in High Wycombe was closed, following a CQC report that gave the unit an overall rating of ‘inadequate’. The CQC found the hospital “not adequately equipped to care for young people with complex needs”. The hospital had only opened in April 2018 and catered for children aged 13 to 17 with learning disabilities and/or autism. In 2018, two of the company’s hospitals, its Roehampton hospital in Wandsworth and its hospital in Southgate, North London, received very critical CQC reports. Both were rated “requires improvement” overall by the CQC, following unannounced inspections. The CQC rated the Southgate hospital as “inadequate” for safety and noted several concerns across its child and adolescent mental health services, acute adult wards and substance misuse services.

Cygnet has been repeatedly criticised by the CQC for unsafe and poor care. From October 2018 to January 2020, 10 of Cygnet Healthcare’s 124 hospitals were rated “inadequate”. More bad reports of the company’s hospitals have been published since.  Finally, in April 2021, NHS England told Cygnet that it will ‘not tolerate failures’. In a letter, reported in the HSJ,  Claire Murdoch, the national mental health director, and John Stewart, national commissioning director, warned Cygnet that “patients deserve better” and they will “not hesitate to take further action” if improvements are not made. Cygnet has difficulties with recruiting staff, a problem not confined to the private sector, but it is also clear from many of the damning CQC reports that there are major issues with the management of the company and leadership within the hospitals.

In June 2021, the CQC published a review of Cygnet Healthcare. The review continues on from the one in early 2019 produced as a result of the Whorlton Hall scandal (although Cygnet did not own this hospital at the time of the scandal), which raised concerns over the use of physical restraint, high reliance on agency staff and vacant management positions, that care and treatment did not always follow best practice, clear lines of accountability were not always apparent, and that ‘fit and proper’ person checks had not been carried out for its executive board. The new review also considered additional concerns that had been raised at 13 Cygnet services during inspections, including ongoing serious incidents, whistleblowing contact and safeguarding concerns.

Some of the most damning conclusions to come from the review concerned the management within the company. The CQC found that the company does “not have a longer term strategic plan” and “members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. ”

There have been at least 21 deaths of patients at Cygnet hospitals across the UK since 2011, according to the organisation Inquest. In March 2022, an inquest concluded that the death of Emma Pring at Cygnet’s Maidstone hospital in April 2021 could have been prevented by the hospital, with the jury finding there had been an “insufficient level of observation, and a misjudgment of Emma’s actual risk”. Pring was not placed on one-to-one observations which might have prevented her death. Pring was supposed to have been observed by staff every 15 minutes, a timeframe which the inquest found was not always adhered to.  The coroner is considering whether to issue a prevention of future deaths notice to Cygnet hospitals. An inquest following the death of 17-year-old Chelsea Blue Mooney at a Cygnet hospital in Sheffield in April 2021, found that “insufficient care” at the hospital had led to her death.

The hospital ‘failures’ continued after the letter from NHS England in April 2021.

There are serious questions over the quality of care for patients at Elysium’s hospitals. Over the past two years, inquests held on three deaths at Elysium Healthcare hospitals found failings by staff at the clinics.  In July 2021, an inquest jury in Milton Keynes found that serious failures of risk assessment, communication, and the setting of observation levels contributed to the death of 19-year-old Brooke Martin in 2019. Brooke, who had diagnoses of autism and emotionally unstable personality disorder, was detained under the Mental Health Act at Chadwick Lodge Hospital, a facility owned by Elysium Healthcare.

In November 2021, inquests held just seven days apart heard how Nadia Shah, 16, and 19-year-old Leon Tasi were found with ligatures round their neck at clinics run by the company. In both cases juries were told inadequate checks had been made on the pair. An inquest jury ruled that Nadia had been failed by the clinic.  A “chaotic” scene then led to a delay in Nadia receiving basic life support. At Leon’s inquest, a coroner was told staff gave him back his belt – which he then used to hang himself. He had been detained under the mental health act. Staff had failed to carry out an hourly visual check to see that he was safe, the inquest was told.

Long-term care, including care homes and home care, is dominated by private companies. Over the years there have been numerous reports of safety issues in care homes and home care. The most notorious being the Winterbourne View case exposed by Panorama in 2011. In November 2018,  an investigation by The Guardian found that “some of the country’s worst care homes are owned by companies that have made a total profit of £113m despite some of the vulnerable people they are supposed to look after being neglected.” CQC reports into the homes list various failings in care and safety issues.

Private Hospitals

The first case that really highlighted the problem with quality when NHS services are outsourced was that of Hinchingbrooke hospital, the running of which was outsourced to private company Circle in 2012. The contract hit the headlines in January 2015, when after only two years of a ten year contract, Circle announced that it was pulling out. The announcement came just before the publication of a damning report on the hospital from the Care Quality Commission (CQC): the CQC raised serious concerns about care quality, management and culture at the hospital.

The CQC found a catalogue of serious failings at the hospital that put patients in danger and delayed pain relief. The hospital was put in to special measures, the first time the CQC has had to do this. Circle cited financial considerations when announcing its withdrawal, but conceded that the report had also been a factor in its announcement.

Circle was also the private provider involved in the privatisation of Nottingham’s dermatology service, which in June 2015, was described by an independent report as “an unmitigated disaster”.

Private hospitals are being increasingly used to perform operations paid for by the NHS; around 500,000 per year. However, the safety and quality of care that patients receive is not always adequate, according to an investigation by the Centre for Health and the Public Interest (CHPI).

In its report, CHPI addresses some of the systemic patient safety issues in private hospitals. These include:

• Post-operative care in private hospitals is usually carried out by inexperienced junior doctors who are working excessively long hours;
• The consultant who carries out the surgery and who is responsible for the patient is permitted to be off-site;
• Nature of this post-operative care has been cited as a factor in a number of patient deaths;
• Lack of intensive care facilities means if something goes wrong then patients have to be transferred back to NHS hospitals, which in itself is very dangerous;
• Data on patient safety in private hospitals is poor and they aren’t required to make this information public in the same way as NHS hospitals are.

In another report, the CHPI also documents the safety issues in private hospitals following the scandal whereby surgeon Ian Paterson wounded 500 women who underwent unnecessary breast surgery in private hospitals. They conclude that until the private hospitals have full liability for the patients under their care, then there will be no guarantee of safety.

The CQC produced its own report in April 2018 prompted by the scandal of the surgeon Ian Paterson. The CQC’s conclusion included that the informal arrangements between surgeons and doctors and private hospitals is a “major concern” which could put patients at risk and that there was “substantial variation in the quality and effectiveness of governance arrangements and a number of examples of poor practice”.

See further reading for more information on problems in the private sector.