Good morning. When the government set about instituting a set of major NHS reforms a decade ago, one senior adviser said they would be a “big opportunity” for the private sector.
For years before that, for-profit companies had been allowed to bid to provide services, but under the new rules, NHS commissioners were allowed to give preferential treatment to internal options if they wanted to. Then health secretary Andrew Lansley’s reorganisation, achieved through the health and social care act, did away with that, outlawing “anti-competitive behaviour” in order to force public and private options to be treated as equal.
But were they? A new study published in the Lancet, and reported on the front page of the Guardian today by health editor Andrew Gregory, tries to explain part of what happened next. It looks at what the reforms have meant for patients through the lens of one vital metric: deaths due to treatable causes. The study finds that an increase in for-profit outsourcing corresponds to an increase in these deaths – and between 2014 and 2019, was associated with more than 550 of them.
Today’s newsletter will look more closely at those deaths, and try to explain what all of this tells us about how more private provision has shaped the NHS. That’s right after the headlines.
Five big stories
Conservatives | Boris Johnson is facing a fresh threat from Tory rebels planning a takeover of the powerful backbench committee that could force the prime minister from office. Rebels hope to take all 18 positions on the 1922 Committee in a secret ballot within the next three weeks.
France | Salah Abdeslam, the only survivor of the 10-man unit that carried out the 2015 Paris terror attacks, has been found guilty of murder and sentenced to life in prison. Another 19 suspects were found guilty of plotting or offering logistical support, with sentences ranging from two years to life in prison.
Policing | A record six police forces are currently judged as failing so badly that they need special help, the Guardian reveals, as a furious political row erupted over the placing of Scotland Yard into special measures.
US news | The singer R Kelly was sentenced to 30 years in prison on Wednesday for sexually abusing women, girls and boys, more than 20 years after first facing allegations.
Politics | MPs should not be allowed to bring babies into the House of Commons chamber during debates, a cross-party review has recommended. Stella Creasy, who brought her newborn son into parliament, said the rules were “antiquated”.
In depth: How the 2012 reforms led to today’s statistics
If you decided at the time that Andrew Lansley’s 2012 reforms to the NHS were simply too baffling to get your head round, you could probably be forgiven: some people thought Lansley (pictured above) and David Cameron didn’t understand them, either.
The health and social care act was a vastly complicated and highly controversial attempt to restructure the health service, with one of its intentions being a sharp increase in the role of the private sector. Even senior Conservatives have since acknowledged it was a failure: David Cameron wrote in his autobiography that “I could and should have stepped in earlier.” In the end, Lansley was sacked.
Nonetheless, there is still a debate about the extent of the reforms’ impact on patients. The new Lancet study, by health policy researchers Benjamin Goodair and Dr Aaron Reeves, tries to put a figure on deaths from treatable causes associated with for-profit outsourcing in the years since. They call it “the first robust empirical assessment” of its kind.
The new data is difficult reading for those who claim it is possible to make the NHS a better service by increasing private provision – but there are also some caveats to it from others who know the field well.
***
What does the Lancet study say?
Reeves and Goodair gathered data from 173 English clinical commissioning groups (CCGs), the local bodies which distribute the money for healthcare services within the NHS (at least, until they are replaced in another reorganisation next month). They estimated the number of additional deaths from treatable causes that were linked to the growth of for-profit outsourcing within these CCGs, and controlled for other factors that might have been responsible for any change.
The study concluded that for every one per cent annual increase in for-profit outsourcing, a 0.38% increase in “treatable mortality” follows – that is, deaths that could have been avoided through effective healthcare for a serious problem. Between 2014 and 2019, they found that around 550 such deaths were linked to private healthcare provision.
Nigel Edwards, chief executive of health thinktank the Nuffield Trust, thinks that the study has “found something real” but that the explanation “may not be what they think it is”. (More on that below.) Another healthcare expert called the study “an innovative way of counting the costs of outsourcing. We haven’t had anything like it before.”
***
What do the figures tell us?
It’s worth putting those 550 deaths in the broader context of the extent of treatable mortality across the NHS as a whole: in England over the same period, ONS data says in this spreadsheet, the total for such deaths stood at about 274,000. (Lest this sound absolutely terrifying, we should be clear that the term doesn’t mean medical malpractice – it means conditions where optimal healthcare will make death less likely, but can’t eliminate it in every case. One expert I spoke to yesterday called it a “dipstick indicator”.) That figure for England includes a few CCGs that aren’t part of the study, so it’s not an exact comparison, but it gives some indication of scale.
But none of this is to trivialise the impact. The study is peer-reviewed, and it finds a statistically significant effect, with real suffering behind the numbers. Outsourcing has risen over this period from less than 4% to just over 6% of spending. The more it grows, the study suggests, the bigger the impact on patient care would be.
And maybe the crucial point is this: proponents of marketisation within the NHS don’t just say that you can achieve the same or slightly worse outcomes in exchange for a saving – they claim it will lead to better treatment. As Lansley said himself when pitching his reforms: “The NHS must be focused on achieving continuously improving outcomes for patients – not inputs or processes, but results.”
***
So why is this happening?
The authors of the study were not able to identify what Andrew Street, professor of health economics at London School of Economics, described to the FT as a “clear causal pathway”. But they suggest that the deaths were “potentially caused by worsening in the quality of health-care services”.
They say that privatisation sits alongside the impact of austerity as a cause of the decline, and speculate on two possible mechanisms: straightforwardly worse care from providers, because for-profit alternatives tend to cut costs; and “cream-skimming” by private services of the easiest cases to resolve resulting in “intensified pressure across the whole health system”.
Nigel Edwards adds a caveat to these points. “The major issue I have with it is that the biggest items in treatable mortality are things like heart attack and stroke – where treatment isn’t outsourced. Most of the outsourcing is in community services and mental health and things like that, where mortality is only marginally connected.”
He suggests another possible explanation: “if you are a deprived area with very tight funding, you may be more likely to outsource. So it’s possible the real underlying driver here is limited resources and austerity.” That doesn’t disprove the “cream-skimming” argument, and Edwards emphasises that it is only a hypothesis – but it does suggest, as the Lancet study also says, that more research is needed.
***
What’s the bigger picture on NHS marketisation?
How long have you got? On the one hand, one feature of the Lansley reforms’ failure is that quite a lot of them never made it into practice, says Edwards: “The heavy marketisation model Lansley had in mind didn’t even reach the statute book.”
But the Lancet study documents a tangible effect on care which stands alongside many other indicators of worsening performance over the last decade – and has led some to decry the gradual “dismantling of the NHS”. And today, with a backlog of 6.5m patients in the aftermath of the pandemic, private companies are being asked to do more.
This Guardian editorial argued in January that a political preoccupation with the private sector has not represented good value for money – or better outcomes for patients. “In England, it is clear that an increased role for the private sector is the government’s plan” to deal with the health service’s difficulties, it says. “[Ministers’] actions in beefing up the role of private providers, while refusing to take the steps that would help to secure the NHS’s long-term future, speak louder than their words.”
What else we’ve been reading
The London 2012 Olympics was supposed to regenerate one of the most deprived parts of east London. Ten years later, Oliver Wainwright’s long read is a depressing, and fascinating, explanation of what went wrong. Archie
In the latest instalment of the Guardian’s heat or eat diaries, James tells us about the harrowing reality of benefits caps that left him with £50 a week to feed his whole family. Nimo
The stunning collapse of the cryptocurrency market - from more than $3tn six months ago to less than $1tn today - is one of the stories of the era. Alex Hern and Dan Milmo explain what happened, and whether it constitutes a “cryptoapocalypse”. Archie
As Pride month draws to an end in the UK and the US, Michael Cuby examines how New York’s ballroom culture has changed over the last five decades asking what it means when an underground subculture becomes enveloped in mainstream society. Nimo
In mitigation for the crimes for which she has been sentenced to 20 years, Ghislaine Maxwell pointed to her unhappy childhood. Dorothy Byrne, who made a documentary about Maxwell, is withering in her analysis of that claim. Archie
Sport
Wimbledon | Andy Murray and Emma Raducanu were both knocked out in the second round at Wimbledon. Cameron Norrie and Novak Djokovic went through while Ukrainian Lesia Tsurenko beat her compatriot Anhelina Kalinina.
Cricket | A late flurry of wickets left England in a commanding position on day three of the Test match at Taunton, with South Africa closing on 55 for three, still 78 runs behind. The day had begun with England’s Nat Sciver completing her 150.
Football | Ahead of the Women’s Euro 2022, this guide takes you through all 368 players taking part in the tournament.
The front pages
The Guardian leads with “Tory privatisation linked to increase in NHS death rates”. The Times has “Troop surge to defence Nato’s east from Putin” while i newspaper says “No extra UK defence cash until 2025”. The Telegraph has “No 10 fears PM faces ‘kangaroo court,’” reporting that allies say Johnson will not get a fair hearing over allegation he misled parliament. The FT leads with “High inflation will persist longer in the UK, Bailey warns”.
The Royal Family makes several front pages. The Mirror has “£100m for the Royals? Reign it in…” while the Express says “Charles ‘would never take a suitcase of cash again’”. The Mail splashes with “Meghan ‘bullying’ inquiry buried”.
Today in Focus
The case against Donald Trump
The US congressional hearings on the Capitol Hill attack have been prime time viewing. And the case against Donald Trump has been building for all to see, says Lawrence Douglas
Cartoon of the day | Steve Bell
The Upside
A bit of good news to remind you that the world’s not all bad
This Saturday, 30 venues across the UK will be taken over by disabled artists for one day. The shows and exhibitions are being organised by Mike Layward, the artistic director of the disability arts charity Dash.
While the artwork that is presented in We Are Invisible, We Are Visible is supposed to represent the spaces that disabled people are made to be invisible even when they’re present, Layward says this isn’t about anger or rage. The collection is supposed to be satirical and edgy, giving space, through performances, visual and audio installations and poetry, to those to whom space is so often denied.
Sign up here for a weekly roundup of The Upside, sent to you every Sunday
Editor’s note: in Wednesday’s newsletter, we incorrectly wrote that “Colombia has suffered from a high rate of femicide” – the country is Bolivia.
Bored at work?
And finally, the Guardian’s crosswords to keep you entertained throughout the day – with plenty more on the Guardian’s Puzzles app for iOS and Android. Until tomorrow.
