'Accident and emergency'? Exploring the reasons for increased privatisation in England's NHS

England's NHS is experiencing rising privatisation as services are increasingly being delivered by private healthcare providers. This has led to concerns about the supposed benefit of this process on healthcare quality but the reasons for the increase - and whether processes prioritise quality - are not well understood. In-depth semi-structured interviews with 20 people involved in the commissioning process, sampled from 3 commissioning sites (regional health boards) are thematically analysed. Four key themes of reasons for outsourcing were identified: unmet need; the "choice agenda"; appetite for change amongst key individuals working at the commissioning body; and the impact of financial pressures. The study concludes that the experience of commissioners navigating the provision of healthcare with worsening social determinants of health and financial austerity means that decisions to use private providers based on anticipated quality are sometimes but not always possible - sometimes they constitute 'accidents', sometimes 'emergencies'.