| 总结: | <p>England’s NHS has experienced increased privatisation via a shift towards the contracting-out of publicly funded healthcare to private providers. Originally founded through a widespread nationalisation of hospitals, the NHS (National Health Service) is considered a symbol of national pride as the crown jewel in the welfare state and one of the core achievements of socialism in post-war Britain. This has made the privatisation of the service a site of fervent political and public discourse. Yet, missing from this debate has been the input of rigorous research into the extent and impacts of privatisation. Given the importance of healthcare provision to population health, it is crucial to understand why the NHS has been privatised and whether privatisation has improved or worsened healthcare quality. This thesis makes three major contributions to these debates by answering: a) what are the causes of NHS privatisation, b) what is the extent of privatisation, and c) what are the impacts of privatisation on healthcare quality?</p>
<p>The first paper of this thesis analyses the association between for-profit outsourcing and quality of healthcare provision. It uses a novel data resource of NHS expenditures which link NHS suppliers to their legal company status, identifying all reported expenditures going to for-profit companies, charities, and NHS organisations. This data enables us to analyse the aggregate effect of privatisation at a population-level for the first time in England. This paper reports that for-profit outsourcing has increased from just below 4% to just above 6% between 2013 and 2020 and shows a consistent increase over this period. Using multivariate longitudinal regression models, the paper finds that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponds with an annual increase in treatable mortality of 0.38% or 0.29 deaths per 100,000 population (95% CI 0·15% to 0·62%; p= 0.0055) in the following year. Given the increase in privatisation over this period, we use the average marginal association from the regression model to calculate how many additional deaths can be attributed to observed changes in outsourcing since 2013. We find changes to for-profit outsourcing since 2014 can be associated with an additional 557 treatable deaths (95% CI = 153-961). The paper concludes that increases in privatisation are corresponding with worse quality care in England’s NHS.</p>
<p>The second paper builds on the first by asking: ‘if privatisation is not improving patient outcomes, why is it increasing?’ and uses the answers to generate theories as to the processes of privatisation. To answer this the paper conducts a thematic analysis of 20 in-depth interviews with NHS commissioners which ask them why they perceive the NHS uses private providers and what factors might explain variation in outsourcing between different commissioning regions. I find that the key themes are: the “choice agenda” and independent provider locations; limited NHS capital; increasing need and the ability of NHS providers to meet it; appetite for change amongst key individuals working at the commissioning body; and the impact of financial pressures on commissioning decisions. A new theory of privatisation is explored from the qualitative results differentializing between ‘managed’ and ‘uncontrolled’ outsourcing. The commissioner-provider relationship sometimes locates decisionmaking power with providers and sometimes with commissioners, but the commissioners are never able to challenge the policy landscape they inherit from central government. The study also concludes that the experience of commissioners navigating the provision of healthcare with struggling NHS providers, worsening social determinants of health and financial pressures means that positive decisions to use private providers based on anticipated quality are not always possible.</p>
<p>The third paper of this thesis asks whether the post-2010 fiscal austerity in England accelerated NHS privatisation. It answers the question of whether, and in what ways, a) NHS underfunding b) Local Authority cuts and c) welfare cuts are associated with the regional changes to NHS privatisation observed since 2010. The paper analyses the aggregate association between changes in funding levels for regions and their relative changes to levels of privatisation. We find that levels of government funding are not associated with regional levels of privatisation. This finding has implications for how we understand the impacts of privatisation on health outcomes. If there were a strong association between finances and privatisation – the association with poor health outcomes may be confounded and ultimately caused by austerity policies. Instead, with these findings, we move closer to rejecting that hypothesis and conclude, rather, that the impacts of privatisation and austerity on health are independent of each other.</p>
<p>The fourth and final paper of this thesis conducts a narrative review of the literature evaluating the impact of health privatisation on healthcare quality across high-income countries. Previous reviews of the private healthcare have focused on comparing quality between private and public hospitals – which does not fully capture the effect of privatisation, that of a transfer from one sector to another. We make an important contribution by including the dimension of time to aggregate the evaluations of transfers from public to private healthcare provision. We find that hospitals converting from public to private ownership status tend to make higher profits, primarily through the selective intake of patients and reducing staff numbers. We also find that aggregate increases in privatisation are frequently corresponding with worse health outcomes for patients. Our review provides reason to challenge the justifications for healthcare privatisation and concludes that the evidence for further privatisation of healthcare services is weak.</p>
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