Abstract
Background
Increasing the use of independent providers has been proposed as a solution to the long waiting times at public hospitals generated by the post-pandemic backlog for elective care. However, the profit-maximising aims of some independent providers may risk cost-cutting behaviours and reduced care quality. Empirical evidence on the extent to which these concerns are borne out in practice is sparse. We aim to examine the quality of acute hospital care provided by the public and independent hospital sectors in England and explore the drivers of variation in quality.
Methods
We construct a unique dataset collating publicly available Care Quality Commission (CQC) quality ratings of independent and public acute hospitals as of December 2022 and 2020. We link these to regional deprivation indices, population estimates, average household disposable incomes, and Referral To Treatment data. We first categorise providers into NHS and Independent hospitals to analyse the association of ownership with quality ratings. To analyse ownership further, we then sub-categorise independent hospitals further and consider whether the organisation provides NHS commissioned care. Thus, hospitals were categorised into seven mutually exclusive categories: NHS provider, commissioned charity, commissioned brand, commissioned independent other, notcommissioned charity, not-commissioned brand, and not-commissioned independent other. We use linear and ordered logistic regression models to assess the association of ownership with quality ratings. In supplementary analysis, we examine consistency over time by comparing the effects on 2022 ratings and 2020 ratings.
Results
Of the 283 NHS hospitals, 47.3% (N=134) were rated ‘Good’, and 41.0% (N=116) were rated as ‘Requires Improvement.’ Of the 453 independent hospitals, 82.3% (N=373) were rated ‘Good’, and 9.5% (N=43) were rated as ‘Requires Improvement.’ On average, independent hospitals had 0.205 (SE=0.0581) higher category quality ratings than NHS providers. All types of NHS-commissioned independent sector hospitals had higher average quality ratings than NHS hospitals, as did noncommissioned branded hospitals. Quality ratings were negatively related to the number of different services provided, suggesting specialisation is associated with higher quality.
Conclusion
We find higher quality ratings for independent providers providing NHS funded care, branded providers, and providers with a narrower range of services. We find no evidence to suggest that outsourced patients will experience lower quality care, although cream-skimming could still be detrimental for NHS services if they are left with a more complex case mix. Overall, our results taken together suggest the increasing number of NHS patients treated in the independent sector do not experience a worse quality of care, especially if providers specialise in a limited number of services.
Increasing the use of independent providers has been proposed as a solution to the long waiting times at public hospitals generated by the post-pandemic backlog for elective care. However, the profit-maximising aims of some independent providers may risk cost-cutting behaviours and reduced care quality. Empirical evidence on the extent to which these concerns are borne out in practice is sparse. We aim to examine the quality of acute hospital care provided by the public and independent hospital sectors in England and explore the drivers of variation in quality.
Methods
We construct a unique dataset collating publicly available Care Quality Commission (CQC) quality ratings of independent and public acute hospitals as of December 2022 and 2020. We link these to regional deprivation indices, population estimates, average household disposable incomes, and Referral To Treatment data. We first categorise providers into NHS and Independent hospitals to analyse the association of ownership with quality ratings. To analyse ownership further, we then sub-categorise independent hospitals further and consider whether the organisation provides NHS commissioned care. Thus, hospitals were categorised into seven mutually exclusive categories: NHS provider, commissioned charity, commissioned brand, commissioned independent other, notcommissioned charity, not-commissioned brand, and not-commissioned independent other. We use linear and ordered logistic regression models to assess the association of ownership with quality ratings. In supplementary analysis, we examine consistency over time by comparing the effects on 2022 ratings and 2020 ratings.
Results
Of the 283 NHS hospitals, 47.3% (N=134) were rated ‘Good’, and 41.0% (N=116) were rated as ‘Requires Improvement.’ Of the 453 independent hospitals, 82.3% (N=373) were rated ‘Good’, and 9.5% (N=43) were rated as ‘Requires Improvement.’ On average, independent hospitals had 0.205 (SE=0.0581) higher category quality ratings than NHS providers. All types of NHS-commissioned independent sector hospitals had higher average quality ratings than NHS hospitals, as did noncommissioned branded hospitals. Quality ratings were negatively related to the number of different services provided, suggesting specialisation is associated with higher quality.
Conclusion
We find higher quality ratings for independent providers providing NHS funded care, branded providers, and providers with a narrower range of services. We find no evidence to suggest that outsourced patients will experience lower quality care, although cream-skimming could still be detrimental for NHS services if they are left with a more complex case mix. Overall, our results taken together suggest the increasing number of NHS patients treated in the independent sector do not experience a worse quality of care, especially if providers specialise in a limited number of services.
| Original language | English |
|---|---|
| Journal | International Journal for Quality in Health Care |
| Publication status | Accepted/In press - 9 Feb 2025 |
Keywords
- Health Care Economics and Organizations
- Quality of Health Care
- Hospital Care
- Public Health
- Private Health