Over half of England’s 4,400 inpatient mental health rehabilitation beds are now run by private companies rather than the NHS, yet no one has compared whether the two sectors deliver different results for patients. This matters because the Care Quality Commission found that independent-sector care costs twice as much and keeps patients twice as long, often far from home. NHS England has urged local commissioners to reinvest in NHS beds, but without evidence on quality or outcomes, those decisions are guesswork. It could be that independent units simply treat the most complex patients—or that longer stays produce better recovery. Alternatively, the two sectors may achieve similar results at very different costs, meaning public money is being wasted. If this research succeeds, it will give NHS commissioners and the Department of Health the first hard evidence on whether the shift to independent providers is clinically effective and cost-efficient. The methods developed here—combining surveys, qualitative interviews, cohort studies, and health economic analysis—could also be applied to evaluate other NHS services that increasingly rely on the independent sector, from community care to elective surgery.
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Background Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. Over recent years there have been major cuts to NHS rehabilitation services across England and increasing reliance on the independent sector. In 2018, the Care Quality Commission reported that over half the 4400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and tended to be provided much further from people’s homes. This influenced a national initiative by NHS England (‘Getting It Right First Time’) to encourage Clinical Commissioning Groups to invest in local NHS rehabilitation services. However, we do not know whether the services provided by the two sectors differ in quality or outcomes. It could be that NHS Trusts send their most complex individuals to the independent sector as their needs cannot be met locally, hence the need for longer admissions; it may also be that longer admissions result in better outcomes. Alternatively, patient characteristics and outcomes may be similar for the two sectors, suggesting that the current situation represents an inefficient use of public resources. There have been no studies investigating the effectiveness of inpatient rehabilitation services that have included the independent sector. Our study will address this gap. Aim and objectives We aim to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical effectiveness and cost efficiency. Methods As it is not possible to compare the two sectors through a randomised trial, our project will triangulate findings from five components. The first two are descriptive and the latter three use epidemiological methods to estimate clinical effectiveness and cost efficiency: 1) a survey to compare the quality of services and patient characteristics involving 60 inpatient mental health rehabilitation units across England (30 provided by the NHS and 30 provided by the independent sector) and 500 patients 2) an in-depth qualitative investigation of patient, family, staff and service commissioners’ experiences and perspectives on inpatient mental health rehabilitation provided by the two sectors 3) a cohort study comparing clinical outcomes in the two sectors for the 500 patients recruited in Component 1, using four related regression analyses that take account of differences in patient characteristics 4) a prospective study comparing clinical outcomes in the two sectors for all users of inpatient rehabilitation services in England on a specific census date, using instrumental variable analysis of anonymised electronic NHS records 5) a health economic evaluation comparing the costs and cost efficiency of inpatient rehabilitation services provided by the NHS and the independent sector using data from Components 1, 3 and 4. In Components 3, 4 and 5 our outcome for comparison of NHS and independent sector services is ‘successful rehabilitation’ i.e. being discharged from an inpatient rehabilitation unit without readmission over the following 18 months. Our methods could also be used to evaluate other areas of the health service that use the independent sector.
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