1. NHS Privatisation associated with worse quality healthcare – study finds
Ben Goodair, Doctoral Researcher in the Department of Social Policy and Intervention at the University of Oxford
Aaron Reeves, Professor of Sociology and Social Policy in the Department of Social Policy and Intervention at the University of Oxford.
The privatisation of England’s NHS, through the outsourcing of services to for-profit companies, has been steadily increasing since the introduction of the 2012 Health and Social Care Act. In fact, a study that we have published details the additional billions of pounds spent in recent years by NHS commissioners on for-profit companies.
Since the introduction of for-profit healthcare providers into the NHS, many have debated the impact this would have on the quality of care received by patients. Some have compared outcomes between patients treated in NHS and independent hospitals but such straightforward comparisons are rarely revealing because a) patients treated in these different sectors tend to have very different health needs and b) there is a potential for ‘knock-on effects’ from outsourcing on NHS providers’ performance which can’t be captured with this comparison. Instead, it is important to also assess the total impacts of outsourcing by testing whether overall levels of privatisation from each commissioner are associated with improvements or declines in quality of care in their local area.
This is exactly what we did. We brought together a variety of data sources that had never been combined before and we able to uncover a rather concerning pattern. When spending on for-profits increases in a given area, there is a corresponding rise in mortality and a worsening of health in the following year.
What does privatisation mean for health service quality?
While important, this association is only from a single study of one dimension of the quality of healthcare provision. Given this, it is important to read this finding in light of the large body of evidence in this area, which also suggests that introducing for-profits into care systems, health services and children’s services might not result in the improvements in quality that is promised by advocates of private service provision.
The fears are that profit motivations from new providers are at a discord with equitable NHS service delivery. This might mean that the services themselves are worse due to cost-cutting and employment practices; or that the whole service suffers from selective provision which results in inequitable outcomes. Either way, the last decade has represented a further shift towards the private provision of England’s NHS services and the evidence suggests this has not resulted in improved quality of care for patients.
Why, then, is outsourcing on the rise?
It may seem a simple question, and an important one given our findings, but one which the government are unable to answer. They maintain that “there has been essentially no proportional increase in NHS spending with non-NHS providers in the last decade”. This is not what the data shows: both the proportion of treatments and the percentage of expenditure on for-profits has risen significantly in the last 10 years.
The increases in outsourcing are to some extent by design. NHS reform has intentionally opened up the service to an external market in the hope that a ‘diverse pool of providers’ can compete for NHS contracts. To achieve this, preferential treatment based on whether the hospital is NHS or independent has been outlawed along with ‘anti-competitive behaviour’ by commissioners. This has resulted in a service which is open to the healthcare market, and we have seen corresponding rises in privatisation.
However, privatisation is not on the rise in all geographic regions, nor across all treatment types, leading to further questions about whether there isn’t some ‘distortion to the level-playing field’ – whereby something other than patient choice and higher quality of care is driving the outsourcing of services. This selective service provision based on relationships or profitability might be of concern given the stringent funding of the service and the direct implications of outsourcing on the quality of care.
There is more that needs to be done to unpack why outsourcing continues but what is clear is that further moves into this area risk undermining patient safety and may increase mortality.
This report is based on the following peer-reviewed research: Goodair, Benjamin, & Reeves, Aaron. (2022). Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: An observational study of NHS privatisation. The Lancet Public Health, 7: e638-e646. https://doi.org/10.1016/S2468-2667(22)00133-5. It previously appeared on the KONP website.
 Expenditure data available from Rahal and Mohan (2022) The Role of the Third Sector in Public Health Service Provision: Evidence from 25,338 heterogeneous procurement datasets. Available at: https://osf.io/preprints/socarxiv/t4x52/ . Treatment data is author analysis of monthly RTT waiting times data.
2. Symposium on Sociological Contributions to Public Health
Symposium report 08 April 2019
A one-day symposium was held to take forward work on strengthening the links between sociology and public health in the UK. The Foundation for Sociology of Health and Illness supported the symposium, which was advertised primarily to the BSA Medical Sociology community through the jiscmail list, and through social media, and hosted by the Social Science & Urban Public Health Institute at KCL in London. Organisers were Judy Green, Fiona Stevenson, Catherine Will and Andrew Guise.
We intended to keep the event small enough to enable all to participate in discussions, and capped registrations at 60. The event was well over-subscribed, suggesting considerable interest in the topic. Attendees were mostly sociologists, working in sociology or medical/health departments, and some representatives from public health practice, PHE and behavioural sciences.
Feedback from the symposium was very positive: participants reported that the day had been stimulating, productive and much needed: there was considerable enthusiasm for building a network and supporting the development of coherent work in this area.
Background and aims
Debates around complexity and causation have opened up spaces for more explicit theoretical and methodological sociological contributions to public health, beyond the traditional ‘concepts’ that form part of public health training, such as stigma or inequality. Novel applications of approaches from (for example) practice theory and new materialisms have been promulgated as offering ways through impasses in health and health equity improvement. To move from exhortation to practice, theoretical insights need to be integrated into real world settings, in collaboration with policy and practice experts. To this end, sociologists have been active in calling for more creative and productiverelationships with public health.
There is a need to capitalise on this interest, and consolidate the visibility of sociology for public health practitioners and policy makers. A recent Public Health England report on social and behavioural sciences in public health called for more ‘social’ research in public health, but the focus of examples was largely from the behavioural sciences. Apart from noting contributions of (e.g.) Normalisation Process Theory, sociology was under-represented. This is in part because sociologists have been less active in organising channels of communication between theory and practice. Interest from Public Health England and other bodies provides a window of opportunity to do this now. To work towards this, the symposium aimed to:
- Showcase recent and ongoing sociological contributions to public health in the UK
- Generate debate on how sociologists can best engage with public health policy and practice for mutual benefit
- Exchange knowledge within the medical sociology community around intersections with public health
- Identify an agenda for a proposed network and study group for sociologists working with public health
- Identify a core working group to take forward a BSA MedSoc special interest study group
The day was organised into two sets of brief (10-15 minute) presentations to stimulate discussion, workshops for participants to share knowledge, and a plenary Q&A to identify next steps.
Presentations in the morning showcased how sociological theory had informed public health interventions and evaluations. Kate Hunt (University of Stirling) discussed how theories of masculinity and social practice had informed the very successful Football Fans in Training intervention for men’s health, and how this was now being extended as the intervention spread around the world. Wendy Wills (University of Hertfordshire) focused on food practices, linking issues of malnutrition, hunger and obesity in her examples to show how habitus and social structures shape possibilities for change. Oliver Bonnington reflected on anti-stigma campaigns in mental health, foregrounding some of the challenges of treating stigma as an issue of attitudes and behaviours, which underplays the material impacts of stigma on lived experience.
Those in the afternoon took three perspectives on relationships with local practice, national policy making and the public to explore how we can foster productive relationships between the stakeholders in social research for public health. Jim McManus (Vice President ADPH and DPH for Hertfordshire) noting that public health was originally a social science, highlighted the stereotypes that public health and sociology might have of each other, reiterated the shared aims of fostering population wellbeing, the need for the whole range of social science disciplines for this, and the need for better integration of sociology into local public health practice: we need to ‘complexify’ public health. Mike Kelly (University of Cambridge) reflected on his time at NICE to point to some of the political and practical challenges of ‘translating’ sociology to busy policy makers, and how sociological theory has been incorporated in many evidence reviews (although often not explicitly). Big gaps in evidence still persist around how to narrow inequalities. Oli Williams (King’s College London) used his experience of co-producing research findings with graphic artists to highlight the need for dissemination to be woven through projects, and how researchers can use innovative methods to share sociological concepts with diverse publics.
Workshops: The workshops addressed four topics in detail: teaching, impact, new theoretical directions; critical collaborative sociology. Participants contributed to one workshop in the morning, and one in the afternoon. Key issues discussed were:
- Teaching sociology in public health courses (Chair: Andy Guise)
Initial questions of who should be taught, what and how, and how this can be supported through common curricula and guidelines, developed in to a rich discussion of the contexts for teaching, and how those seeking to teach can work together. The discussion included elaboration of particular concepts and theories that should be the focus for teaching, and then how sociology has a unique contribution to make to the training of public health professionals.
Suggested next steps include developing a sociological ‘core course’ for the Faculty of Public Health training, a masterclass for sociologists working in public health teaching, and in support of these to develop a community of practitioners (developing from the workshop) to develop these ideas, linking in the first instance to a detailed mapping of current teaching and then opportunities.
- Maximising the impact of sociology on public health (Chair: Barry Gibson)
Need for a platform for public health and sociology to think with each other – sociology often comes to the table too late, and critical engagement is needed early on. Sociologists could help with ‘translating’ theorists, and there are opportunities in the move of PH to local authorities. Question of what do we mean by impact, and impact for whom? Best thought of as a reflexive process. Need for inter (not multi)-disciplinary approaches (e.g. biopsychosocial models) that acknowledge tensions. We could do with some exemplars on improving public health – successes still tend to focus on downstream examples. How can we measure things, yet still reflect complexity? (especially when funding still focused on narrow outcomes)
- New theoretical directions (Chair: Benjamin Hanckel)
Participants acknowledged the tensions that emerge in bringing sociological theory into conversations with public health. There is a need to find ‘common ground’ (or productive tensions?), where it is possible to contribute to health policy and practice. It was acknowledged by participants that the institutional contexts for doing this work are emerging, where, for instance, interdisciplinary work is valued by the institutions we work within (particularly in relation to the REF).
The following key issues were explored in this workshop:
- Participants discussed how we use and understand the term ‘theory’ across (and within) the disciplines/fields we are in. In particular there are differences regarding the use of the words: ‘theory’, ‘social theory’, and ‘sociological theory’.
- There were concerns raised regarding how the concepts we use travel and get (re)interpreted different across disciplines/fields (i.e. ‘social norms’ and ‘inequalities’).
- Participants also discussed the possible opportunities for learning through engagement with public health. There was, for instance, discussions about how sociological theory might be able to participate in and build on debates in public health, particularly where sociological theory has been largely absent (e.g. complexity/complex systems). It was also acknowledged that there are opportunities here to extend sociological theory, where engagement with public health could lead to building on our existing theoretical tools/concepts.
- Participants discussed how both existing and emerging sociological theory can make an important contribution to public health research. Some of the theoretical ideas discussed during the workshop included the work of symbolic interactionists (i.e. Goffman), social practice theories, Giddens’ structuration theory, intersectionality, recent work on affect, as well as Southern theory. These, amongst others, provide useful frameworks for framing problems, and, in particular, speak to sociological strengths: the examination of inequalities; historically situated research; and in-depth exploration of communities/cases.
- Maintaining a critical collaborative sociology (Chair: Robin Bunton)
Participants discussed need to balance critique with practical and respectful approach – problematising everything is not popular/need to offer positive alternatives; why ‘sociologist’ and ‘public health’ are mutually exclusive (unlike say epidemiology) – PH practitioners also want to engage in critique – there is appetite for research, reflexivity and theory in public health practice; structures of funding limit critique; need to be more explicit about theory (not tacked on/hidden); sociology can be reduced to ‘qualitative health research’; growing recognition of ‘complexity’ is an opportunity; problem of split of sociologists in sociology departments writing monographs, and those in PH working on fixed term contracts; space for people to be honorary members of sociology departments?; there is no landmark textbook on sociology for/of/with public health.
Q&A and discussion
The panel, comprised of the presentation speakers, and chaired by Judy Green, addressed questions from the floor, and reflected on what made the relationship between public health and sociology ‘work’ when it did. It was noted that lots of good local collaboration went on through CLAHRCs, and on specific projects. These took time to develop, and relationships took time to foster, which was made more difficult in contexts where there is organisational restructuring. There is much common ground between sociology and public health – we need ways to build on this, and make sociological ideas more available to those in PH who want to use them. There is a tension between being explicitly sociological and potentially off-putting, but wanting to label what we do so it is visible. We could consider a ‘core course’ for sociology with public health, with debate on what should be taught, to whom and how. This symposium has had good reach with those involved in BSA Med Soc, but there may be other constituencies that we have not involved to date, and, moving forward, we could consider how to include sociologists whose work is relevant to public health outside the sub-discipline. We need to consider audiences: which public health constituencies might welcome what kinds of resources, and how can we help provide them?
Speakers, chairs and participants were thanked for their input into a very productive day; Shayda Kashef thanked for all her hard work in managing and publicising the event, and Nuria Camiña Garcia and Emma Goettke thanked for their help on the day.
- Work with Faculty of Public Health to update medical sociology curriculum
- Consider ways of collating examples of good local practice examples
- Establish a network of sociologists working with public health, using initial participants as starting point, and consider a BSA Med Soc study group
- Volunteers offered to join a team to take this forward, including future events in the north of England and Scotland
- Possible research project to scope examples of effective joint working.
Possible longer term plans
- Textbook of sociology for public health
- Contributions to public health journals
- Paper for the behavioural sciences network
- Developing resources for web sites for public health directors/practitioners