Intended for healthcare professionals


Private patient care in NHS hospitals: an opportunity for improved governance

BMJ 2020; 370 doi: (Published 18 September 2020) Cite this as: BMJ 2020;370:m3363
  1. Sarah C Walpole, specialist registrar doctor in infectious diseases1,
  2. May CI van Schalkwyk, NIHR doctoral research fellow2,
  3. Martin McKee, professor of European public health2
  1. 1Newcastle University, Newcastle, UK
  2. 2Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to: SC Walpole sarah.walpole{at}

The 2012 NHS reforms in England allowed trusts to generate more income from private practice in the expectation that this would support improved NHS care, but, as Sarah Walpole and colleagues show, existing governance arrangements provide no assurance that such benefits are being realised

The 2012 Health and Social Care Act was the largest ever reorganisation of the English NHS.1 It attracted considerable controversy and changed substantially over 50 days of parliamentary debate.2 An independent analysis found that, although it had the potential to improve care, it also created numerous risks.3

The ideological underpinning of the initial act was that a market would increase patient choice, with greater competition through diversity of supply.3 But this attracted concerns about commercialisation of the NHS, encouraged by revelations about conflicts of interest (COIs) of parliamentarians.45 The accompanying secrecy, with the government rejecting calls from the Information Commissioner and the Information Rights Tribunal to disclose the risk register of the act, offered little reassurance.6

One of the many amendments, introduced just before Christmas 2011, as the act was completing its parliamentary passage, changed a key clause. It raised the cap on income that NHS foundation trusts could earn from privately paying patients.7 When foundation trusts were proposed in the 2003 Health and Social Care Act, concerns were raised that they would prioritise private income at the expense of NHS patients. In response, the government imposed a cap at between 2% and 30% of the trust’s income, based on what it had earned in its “baseline year” (when it first became a foundation trust). The 2012 act raised the cap to 49% of income. Andrew Lansley, then health secretary, said “If these hospitals earn additional income from private work, that means there will be more money available …

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