- Utkarsh Ojha, internal medicine trainee (joint first author)1,
- Akbar Karimi, foundation trainee (joint first author)2,
- Pranev Sharma, cardiology trainee1
- Utkarsh Ojha on Twitter: @DoctorKarsh
Pranev Sharma on Twitter: @psmedic
The NHS faces a substantial challenge in dealing with the backlog in clinical, diagnostic, and procedural waiting lists after the covid pandemic. NHS England has considered increased outsourcing to the private sector to tackle the growing demand.1 Private sector provision of NHS services has always been a contentious issue in the UK: economic, social, and ethical arguments are frequently highlighted in opposition to a privatised healthcare system. Outsourcing NHS services to private companies has further been linked to avoidable deaths.2
The impact of NHS outsourcing on medical training is often overlooked. The rise in healthcare privatisation can pose a challenge to medical trainees and may result in dropped standards in clinical care, service provision, and patient safety. Since the covid pandemic independent healthcare service providers have garnered a greater share of NHS care, which has risen from under 4% of total expenditure in 2013 to over 6% in 2020.2 This has raised concerns, particularly among UK medical trainees. A recent survey by the Royal College of Ophthalmologists highlighted that, although having access to independent healthcare providers’ training facilities and patient lists was a positive experience for most trainees, accessibility varied considerably by region.3
Medical trainees have also reported inconsistency in training at some independent healthcare facilities, with no clear training programme or named supervisors.3 Training opportunities were found to be more accessible for senior trainees, including trust grade doctors, who already had significant experience and required less intensive supervision.3 This lowered the morale of junior trainees and led to anxiety about completing their training.3
Recent contract disputes and industrial action by doctors have placed workforce issues at the forefront of our minds. A common short term method to fill workforce gaps is for hospitals to advertise locum work, but opportunities for locums in the private sector are increasing. Private locum posts can provide rates better than those offered by the NHS, often for comparatively lower acuity work.4
Private providers may also advertise longer term vacancy posts with more competitive salaries, which could lure more junior doctors away from NHS work.4 Recent analysis of orthopaedic training in the independent sector has shown that private institutions in their current state can’t fulfil curricular needs.5 Nevertheless, such financial incentives still attract medical trainees who would otherwise fill NHS rota gaps.
Less exposure to complex cases
Substantial geographical differences in the availability and use of independent healthcare service providers for NHS care in the UK suggest a potential “brain drain” of medical trainees from more rural areas towards independent training centres for better pay,6 which would compound current problems in service provision and the workforce. It’s not uncommon for rota gap demands to result in more junior trainees having to “step up” and act above their competency.7 This not only affects their own training but poses a concern for patient safety.
The use of private services can lead to preferential selection of patients for financial gain, leaving NHS services to deliver more demanding treatments.2 The Private Healthcare Information Network reported that one in 1000 private patients8 required transfer to an NHS hospital after procedural complications. Another report found that every percentage point increase of private outsourcing corresponded to an annual increase in preventable mortality of 0.38%.2 Several reasons have been suggested to explain this association, including less adherence to standardised guidelines.29 Previous concerns had been raised about lax standards of vetting and training in private centres.10 The preferential selection of patients in the independent sector thus reduces trainees’ exposure to complex cases11 and risks creating a new generation of consultants with less competency.
The NHS continues to face substantial challenges in tackling the backlog of medical services after the covid pandemic and, more recently, strikes by junior doctors and consultants. As outsourcing of services to the private sector increases we should listen to the concerns raised by medical trainees about its disruptive impact on their training. Provisions will need to be introduced to prevent inequity in access to training at private institutions on the basis of geographical location. And a greater focus on appropriate workforce distribution is needed to avoid exacerbating existing staff shortages.
In a post-pandemic era, balancing the demands of service backlogs while ensuring that the standards of junior doctor training aren’t compromised is essential, both for the long term sustainability of the NHS and for maintaining the safety and quality of patient care.
Footnotes
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No specific grant from any funding agency in the public, commercial, or not-for-profit sectors was received for this article.
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Competing interests: None.
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PS, UO, and AK were equally involved in drafting, design, data acquisition, and analysis. All authors gave final approval of the manuscript and agree to be accountable for all aspects of the work.
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Provenance and peer review: Not commissioned; not externally peer reviewed.
