Intended for healthcare professionals


“A gift to the sector”: why did the NHS’s contract with independent hospitals allow private patients to be treated when the NHS was overwhelmed?

BMJ 2023; 380 doi: (Published 15 February 2023) Cite this as: BMJ 2023;380:p348

Linked Investigation

The NHS paid private hospitals £2bn in the pandemic: did taxpayers get value for money?

  1. Sid Ryan, researcher
  1. Centre for Health and the Public Interest
  1. s.ryan{at}

When the covid inquiry looks at the £2bn contract with the private hospital sector1 the central question should be: what did the NHS do with the additional capacity from the private hospital sector when the UK was undergoing its worst ever public health crisis?

Did it make the best use of private hospitals to ensure that patients were treated on the basis of need rather than their ability to pay? Did it deploy them effectively to keep waiting lists down? Or did it allow them to be used by fee paying patients, potentially to the detriment of overwhelmed NHS trusts?

The original oversight was a failure to prepare. The UK entered the pandemic without a clear plan on how to tackle it, or the capacity to do so, and there seems to have been little thought ahead of time about how best to utilise the healthcare facilities in the private sector during a crisis. The rushed decision to abolish local contracts with the private sector and strike a national deal with 27 private hospital companies allowed these companies to dictate highly favourable terms to the government. This needn’t have been the case, as the government had considerable leverage over the sector and should have used it. The health secretary’s emergency powers could have allowed him to order private hospitals to do anything necessary to support the pandemic response.2

Although the government was understandably desperate to obtain any additional capacity, this shouldn’t have put the private sector negotiators in such a commanding position. What resulted was a gift to the sector: the decision guaranteed to pay most of the companies’ operating costs, didn’t include any activity targets, and allowed these hospitals to perform their core business of treating private patients.

Politically convenient

Under this contract, by the summer of 2020 NHS England had bought up entire private hospitals that weren’t being effectively used, and it had an opportunity to renegotiate with the private sector to increase the number of NHS patients being treated. But instead of incentivising the treatment of more NHS patients, NHS England offered financial rewards to fill the capacity with private patients.

Unsurprisingly, after incentivising private hospitals to focus on fee paying patients for most of 2020, several private hospital groups treated more private patients than NHS patients. And when the second wave hit in January 2021, NHS leaders in London were reportedly left pleading with their own consultants3 to stop doing non-urgent private care in independent hospitals and to turn their attention to treating seriously ill NHS patients.

The end results of this contract were an estimated cost of £2bn,45 delivery of little inpatient care for covid patients, less NHS care in 202067 than in 2019, and incentives for the treatment of potentially less urgent, fee paying private patients.

It’s easy to simply blame the NHS for this private hospital contract not living up to expectations. Why does NHS England continue to shield the other parties to this agreement from scrutiny, citing commercial confidentiality despite NHS England and the Independent Healthcare Providers Network promising transparency?

This contract was politically convenient but practically flawed. It generated positive headlines and the appearance of decisive action, but its failure to ensure provision of care to those in greatest need is likely to have had consequences for individual patients, which the public inquiry will need to carefully examine.

Business is now booming in the private healthcare sector. From 2019 to 2022 the number of people paying out of pocket for a hip operation has nearly tripled,8 while NHS waiting lists are at record highs. We will never know what the situation could have been had the government put private hospital facilities fully at the disposal of the pandemic response, rather than encouraging the continued growth of for-profit healthcare in the UK.


  • Competing interests: I am employed by the Centre for Health and the Public Interest (CHPI). The CHPI’s funders have no influence on our research. I live with my father, who is an NHS respiratory consultant and has a private practice with Nuffield Health.

  • Provenance and peer review: Commissioned, not peer reviewed.