The private sector provides a huge range of clinical and non-clinical services to help deliver the day-to-day running of NHS hospitals and also provides an increasing amount of elective care for NHS patients that would previously have taken place within an NHS hospital.

The lack of NHS capacity due to years of underfunding means that more patients are being referred to private hospitals for their NHS elective surgery. Years of a culture of outsourcing of support services, means that private companies, such as Mitie and ISS, have large multi-year contracts for all aspects of facilities management of hospitals, including cleaning, maintenance, and catering. More recently, insourcing where private companies work within NHS hospitals delivering elective surgery on behalf of the NHS, has become commonplace. There have been several years of hospital trusts seeking to create their own private companies to undertake non-clinical work.

Recent Developments

England's NHS waiting list stood at 7.61 million in November 2023, this covers 6.39 million people (some are waiting for more than one procedure). The Conservative government’s answer to tackling this waiting list, has not been to invest in the increasing capacity of the NHS, but to encourage the private sector to take a larger role.

The latest Department of Health and Social Care Annual Report and Accounts (2022-23) show spending of £16.6bn on non-NHS providers, within this area only the spending on independent providers has increased (to £11.5bn from £10.9bn), whereas other non-NHS sectors spend has declined (e.g., LA, voluntary sector). The increase in spending on non-NHS bodies appears to be in ophthalmology services, with ICBs and the Royal College of Ophthalmologists complaining that private opticians on high streets have been increasingly referring patients directly to private clinics offering cataract surgery, with the NHS having no say, and no choice but to pick up the bill.

An investigation by HSJ published in February 2024 reported that up to 20% of NHS elective patients are now being treated by private hospitals in some areas. Before the pandemic the percentage was around 8 to 10% nationally. Now three quarters of the 42 local integrated care systems have seen a rise.

The highest levels of referral to private hospitals In the three months to November 2023 were 20% in the neighbouring ICBs covering the Bristol, Bath and Swindon areas, followed by Sussex (18%); then West Yorkshire and Mid and South Essex (17%).

This increase in elective surgery being carried out in the private sector has been encouraged for many years, but these last 18 months has seen a massive push from the Conservative government to move work into the private sector. In December 2022, Rishi Sunak set up a taskforce focused on the recovery of elective surgery activity and bringing down the waiting list, which included a large number of representatives from the private sector. 

A quarter of the 17 places on the taskforce are taken up by representatives of the private sector, including Independent Healthcare Provider Network (IHPN) boss David Hare, Dr Paul Manning, chief medical officer of US-owned Circle Healthcare, owner of the UK’s largest chain of private hospitals, Darsjak Shah from private eye health firm Newmedica, and Medefer CEO Dr Bahman Nedjat-Shokouhi.

In addition to minister Will Quince, the taskforce also included two right wing government advisors, Robert Ede from neoliberal think tank Policy Exchange and Bill Morgan, founding partner from PR and lobbying firm Evoke Incisive Health whose clients have included the IHPN, Virgin Care (now HCRG Care), and private mental health provider Cygnet.

One of the outcomes of this controversial taskforce, announced in May 2023, was a plan for a new push to persuade patients to use the NHS app to “book private healthcare.” Under the plan the role of the NHS app would be enhanced so that patients stuck on the waiting-list could use it to check how long they would have to wait for surgery at NHS and private hospitals. They would then book their procedure at whichever best suited them.

The taskforce’s final report in August 2023 focused on ways of maximising the use of private hospitals and on getting private providers to run the new Community Diagnostic Centres (CDC). 

The main headline on the report was the announcement of 13 new Community Diagnostic Centres (CDCs), eight of which are to be run by the private sector.

NHS England has so far approved over 50 schemes with independent sector involvement, including fully independent sector-led CDCs, joint service delivery models and CDCs that have made use of independent sector-delivered mobile diagnostic facilities.

A report from The Health Foundation in April 2023 on the use of private providers in ophthalmic and orthopaedic care to ease NHS waiting lists, however, cast into doubt whether use of the private sector would clear the backlog, concluding that it would only have a limited impact on the waiting list:

"The NHS faces a significant challenge to deliver the scale of growth required to bring the waiting list down. The independent sector is showing it can contribute to addressing the elective care backlog in some areas of treatment, but it is likely to play a limited role in fully recovering services and won’t be a substitute for addressing the major problems facing the NHS."

Despite the taskforce and CDC development, it is unclear whether the private sector can really have an impact on the waiting list.


The private sector is involved in NHS hospitals in a number of ways:

  • Elective surgery
  • Facilities management
  • Hospital management
  • Private patient care
  • Spin-off companies for support services

Elective Surgery

The private sector has the greatest involvement in NHS hospital care through elective surgical procedures, in particular in hip and knee surgery and ophthalmology with cataract procedures.

By early 2020, over a decade of underfunding, beds cuts, and lack of a workforce plan (with the additional problems that brexit brought to staff numbers) meant the waiting list for elective surgery had risen to its highest level ever at 4.45 million. The following two years of Covid-19 pandemic pushed it even higher to 6 million by February 2022 and by November 2023 the waiting list stood at 7.61 million in England.

Bed reductions have played a significant role as numbers of acute and mental health beds fell year on year since the austerity regime was imposed by the Cameron government in 2010, with over 13,000 acute beds and 25% of mental health beds closed.

Successive Conservative governments from 2010 have refused to fund increasing NHS capacity at a sufficient level to have any impact on the waiting list, so hospital trusts and other commissioning bodies turned to contracts with the private sector. The result is that the number of NHS patients being treated in private hospitals has increased significantly since 2010.  

For 2019 the independent sector carried out 32.9% of NHS-funded knee replacement procedures and 28.9% of NHS-funded hip replacement procedures. More recently the BMA has estimated that NHS trusts’ spend on independents rose by 659% between 2012 and 2021.

The FT reported in December 2023 that approximately one third of NHS-funded hip and knee operations are now carried out in private hospitals.

In the area of ophthalmology, the private sector is now doing vast numbers of cataract operations. The Royal College of Ophthalmologists has reported that in 2016, 11% of NHS cataract procedures in England were delivered by private companies, but by April 2021 there was almost a 50/50 split, with 46% in the private sector and 54% by NHS trusts and treatment centres.

Private companies get paid to carry out hospital-based work on NHS patients in two ways:

  • outsourcing, whereby private companies perform elective procedures on NHS patients within their hospitals, and
  • insourcing, whereby private companies are paid to carry out elective procedures on NHS patients within NHS premises during what is termed 'downtime' for equipment and theatres, such as the weekend.


For many years commissioning bodies (NHS England, NHS trusts and CCGs) have had contracts with private hospital companies for them to carry out elective procedures within their private hospitals. For some companies, such as Spire, it has been the mainstay of its business. The Covid-19 pandemic and the government's more recent drive to bring down waiting lists has opened up further opportunities for private providers to work for the NHS.

In March 2020 at the start of the pandemic, the government agreed a contract to block-book the entire capacity of all 7,956 beds in England’s 187 private hospitals along with their almost 20,000 staff. It is reported to have cost around £400m a month. The plan was for the private hospitals to treat covid-19 patients as well as providing Covid-19 free hospitals to carry out NHS elective surgery and cancer treatment, as the NHS hospitals began filling with Covid-19 patients. The contract was published in October 2020 and listed as worth £1.65 bn.

The published contract reveals that £1.57 billion was shared between 26 private hospital corporations, each of which picked up payments ranging from £0.9m up to the largest share of £346.6m which went to Britain’s largest private hospital group, Circle Health, having completed the take over the previous market leader BMI Healthcare in mid-2020.

The other big winners were Spire Healthcare Ltd (£345.9m), Australian-owned Ramsay Health Care (£271.1m), Nuffield Health (£165.2m), US-owned HCA International Ltd (153.2m), and Care UK with £76.3m. The remaining £218m was split between 20 smaller companies.

A second set of contracts for January to March 2021 was worth up to £474m. Unlike the first set of contracts, these included minimum payments for making capacity available, as well as for services that were actually used.

Prior to the pandemic, private hospitals undertook 3.6m NHS-funded planned procedures in 2019, which dropped to only 2m during the first year of the pandemic – a fall of 43%. Two letters had been sent to the wider NHS explaining why the deal had been struck and what it would cover, which make it clear that it would include care for Covid patients with serious breathing problems as well as routine operations, such as hip and knee replacements. However, The Independent Healthcare Providers Network, which negotiated the deal on behalf of private hospitals, insisted that it was never intended to cover people with Covid. 

In mid-2021 the government announced the NHS Increasing Capacity Framework contract which is valued at £10bn over four years. This framework contract creates a list of independent providers that can be asked to carry out NHS work and is part of the government's plan to tackle the waiting list for elective procedures. The plan was for it to begin in November 2020 and run to 2024.  Most leading independent hospital companies have now signed up for the contract and the framework will lead to outsourcing significant amounts of routine activity to independent hospitals.

The current framework listed for outsourced elective services on the NHS Shared Business Services (SBS) site runs until March 2024 with 13 independent providers listed. Although the actual contract for the NHS Increasing Capacity Framework awarded in four stages lists over 50 companies.

In February 2022, Sajid Javid, the then Secretary for Health and Social Care, announced the Elective Recovery Plan to reduce the waiting list. The plan contained a number of initiatives intended to get back to most patients waiting no longer than the supposed 18-week maximum. Integral to the plan is the increased use of the private sector, whether this be by outsourcing work to private hospitals or insourcing, whereby private companies use NHS facilities to carry out elective procedures on NHS patients.

In December 2022, Rishi Sunak set up a taskforce focused on the recovery of elective surgery activity and bringing down the waiting list. 

As outlined above, the taskforce contained a large number of representatives from the private hospital sector and right-leaning think tanks. The taskforce recommended several measures to push the increased use of the private sector, including a new push to persuade patients to use the NHS app to “book private healthcare,” and contracting private providers to run the new Community Diagnostic Centres (CDC). 

It is unclear, however, whether the private sector can really have an impact on the waiting list.

A report from The Health Foundation in April 2023 on the use of private providers in ophthalmic and orthopaedic care to ease NHS waiting lists concluded that it would only have a limited impact on the waiting list:

"The NHS faces a significant challenge to deliver the scale of growth required to bring the waiting list down. The independent sector is showing it can contribute to addressing the elective care backlog in some areas of treatment, but it is likely to play a limited role in fully recovering services and won’t be a substitute for addressing the major problems facing the NHS."

The major problems being lack of workforce in the NHS (and in the private sector to a certain extent) and lack of funding to actually carry out work, whether in the NHS or in the private sector.

In February 2022, NHS England's annual accounts reported that the NHS commissioners’ spending on private healthcare increased 27% to more than £18.4bn in 2020-21, with pandemic effects causing it to rise faster than spend on NHS trusts and general practice. In the 2021/22 accounts spending had dropped back slightly to £17.0bn, but still above the 2019/20 figure of £14.4bn.

The latest Department of Health and Social Care Annual Report and Accounts (2022-23) show spending of £16.6bn on non-NHS providers, within this area only the spending on independent providers has increased (to £11.5bn from £10.9bn), whereas other non-NHS sectors spend has declined (e.g., LA, voluntary sector). The increase in spending on non-NHS bodies appears to be in ophthalmology services, with ICBs and the Royal College of Ophthalmologists complaining that private opticians on high streets have been increasingly referring patients directly to private clinics offering cataract surgery, with the NHS having no say, and no choice but to pick up the bill.


Insourcing involves private companies conducting medical procedures, such as surgery and diagnostics, in NHS premises in downtimes, primarily the weekend, when the NHS is not using the premises. The staff they employ are generally full-time NHS employees who work on their rest days.

A national framework agreement in place with NHS Shared Business Services lists 40 companies. These companies have already gone through a competitive tendering procedure to be put on the list and can be used by hospital trusts without additional contract tendering. An initial framework began back in 2018 and ran until September 2022. A new framework began in July 2023 and runs until July 2027. However, trusts are also using companies that are not listed on this framework.

More details of insourcing can be found on a separate page here.

Facilities Management

Many hospitals have outsourced all aspects of facilities management, often under large multi-year contracts covering every aspect, such as cleaning, catering, building maintenance, car parks, and grounds maintenance. Even if a large facilities contract is not in place, catering and cleaning are often outsourced. Hospitals built under the Private Finance Initiative (PFI) always resulted in a long (20-40 years) facilities management contract once the hospital was up and running, often with a company involved in the initial building.

For more details see our pages on PFI.

Hospital Management

The most extreme example of private involvement in an NHS hospital, to date, was the contract awarded to Circle in 2011 for the complete management of Hinchingbrooke Hospital near Cambridge

This ten year contract to run Hinchingbrooke Hospital began in February 2012. Under the agreement, the staff and assets remained part of the NHS. At the time Hinchingbrooke hospital had a debt of approximately £39 million, which Circle needed to eliminate if it was to make a profit from the contract.

The Hinchingbrooke contract was a disaster for Circle in both financial and reputational terms. A report by the National Audit Office in September 2012, noted that Circle had already missed its own financial target for the Hinchingbrooke contract, generating a deficit of £4 million by September 2012, £2 million behind where Circle said it would be.

To try and make the contract financially viable, Circle needed to make big savings at the hospital and this led to a drastic reduction in care quality. Savings were made at the expense of staff, with between 270 and 300 jobs being cut and several wards lying empty. The hospital fell from joint-highest in the area in a patient satisfaction survey to nineteenth out of 46 hospitals trusts across the NHS Midlands and East region in August 2012.

In early 2015 as Circle announced that it was terminating the contract to run Hinchingbrooke, the CQC released a report on the hospital. The report rated the hospital as inadequate and the hospital trust was put into special measures.

Private care in NHS hospitals

Before the introduction of the Health and Social Care Act in 2012, hospitals were only permitted to make 2% of their income from private sources. However, when the legislation passed this cap was lifted to 49%. Trusts rapidly began taking advantage of the change in rules. Figures released quietly by the government acknowledged that the NHS in England made nearly £584 million from private patients in 2016/17, a nearly 29% increase from 2011/12.

In September 2023, University of York academics looked at six high-profile NHS trusts as case studies and found them to be making between 12 and 53% of their total income from commercial activities in 2021/22, including activity from treating private patients and running labs and pharmacies to establishing branches abroad.

They found the “top earner” from commercial income was Guy’s and St Thomas’ NHS Foundation Trust which made £441m in 2021-22 (16.7% of its overall income). The Royal Marsden NHS Foundation Trust generated the biggest proportion of income from commercial work at 53%. The complete findings were published in Public Money & Management.

The researchers concluded that there is a “clear direction towards commercialisation” which has been aided by legislation passed by the Coalition government in 2012.

In 2021, The Lowdown reported that Oxford University Hospitals Foundation Trust was seeking to expand its private patient care, despite a massive waiting list of NHS patients. Then later in 2021 The Lowdown reported that the Royal Marsden NHS Foundation Trust, as RMH Private Care, is seeking private partners to expand their private patient income, after the opening of its new diagnostic and treatment centre in Cavendish Square, central London. RMH Private Care is already the UK’s most lucrative NHS Private Patient Unit.  The Financial Times reports that the Trust earned £132.6m from private patients in the year to March 2020, up 9% from £121.3m the previous year and up 44% from £92m in 2016/17: “income from private patients now accounts for 36% of the trust’s patient revenue, and 29% of total revenues.”

These private patients are being treated by NHS doctors in NHS beds so private patients looking for world class facilities are using beds and services that should be provided by the NHS to our whole population.

Dr David Wrigley, a GP in Carnforth, north Lancashire said: “The fact private patients can jump the queue for treatment flies in the face of the founding ethos of the NHS – that all patients are seen as equal and treated according to need and not the ability to pay.”

More recently an Observer investigation published in January 2023 found that NHS trusts with record waiting lists are promoting “quick and easy” private healthcare services at their own hospitals, offering patients the chance to jump year-long queues. Hospitals are offering hip replacements from £10,000, cataract surgery for £2,200 and hernia repairs for £2,500. MRI scans are offered for between £300 and £400.

The Observer investigation found several examples including: East Sussex healthcare NHS trust has thousands of patients waiting for diagnostic tests but offers “fast access” to scans through its private division; Great Western hospitals NHS trust in Wiltshire tells patients that services are “extremely busy”, but its private division promotes self-pay treatment for those who “don’t want to wait for an NHS referral”; and James Paget university hospitals NHS trust in Norfolk advertises private services on its NHS website, stating: “We provide highly experienced consultant-led services … without the waiting list.”

In February 2023, HSJ reported that Sulis Hospital Bath, which Royal United Hospitals Bath Foundation Trust acquired from Circle Health Group in 2021, was advertising its private services and encouraging its use by highlighting the long NHS waiting times which the trust is supposed to be addressing.

Spin-off Companies for Support Services

In recent years there has been a rise in the number of spin-off companies within the NHS, which can be described as a form of back-door privatisation. These spin-off companies, wholly owned by the trust, employ non-clinical staff such as porters, cleaners, and maintenance staff. More details of this phenomenon can be found on our dedicated pages on Spin-off Companies. Campaigns against this type of back-door privatisation by unions has now decreased the development of such spin-off companies, however.


There are concerns with every aspect of privatisation in hospitals.

Reduction in quality of care

In March 2024 a review published by researchers at the University of Oxford in The Lancet concluded that privatisation of healthcare results in a reduction in quality of care. The study’s authors from the University of Oxford, concluded that:

“At the very least, health-care privatisation has almost never had a positive effect on the quality of care.”

Adding that their review:

“provides evidence that challenges the justifications for healthcare privatisation and concludes that the scientific support for further privatisation of health-care services is weak.”

The published review looked at studies made of healthcare systems in eight high-income countries, where privatisation has been taking place over the past 40 years. Studies included those from the UK, USA, Canada, South Korea, Germany, Sweden, Croatia and Italy.

The review aimed to assess whether the often-stated aim of privatisation – to improve the quality of care through market competition – did indeed occur. Or, is the impact negligible, or in fact to worsen the quality of care due to the profit-driven nature of the organisations.

The study included longitudinal studies – those performed over time – which although small in number provided some of the most useful information. The researchers found a consistent picture of privatisation adversely affecting the quality of care. In these studies, they found that although outsourcing can reduce costs, this was at the expense of standards.

Although an assessment of the financial changes that privatisation brought about was not a primary aim of the study, the researchers did find that hospitals moving from public to private ownership status tended to make higher profits than public hospitals that did not convert. The primary way this happened, however, was through the selective intake of patients and reductions in staff numbers.

The review also has implications for all the theoretical arguments made in favour of privatisation in many areas, noted the authors, as their evidence “does not align with the expectations of mixed markets, namely that they would improve quality by increasing competition.”

It was not just profit-driven companies that were studied, transition to not-for-profit private organisations was also found to frequently have a detrimental effect on the quality of care, although to a lesser extent than moving to for-profit provision.

The authors noted that there will always be issues with the studies that have been carried out over in this area. They tend to focus on inpatient care, and there are very few studies on other aspects of health care such as community, primary, and ambulatory care. The studies also tend to look at staffing levels and are often missing public and patient perceptions of the services provided.

The Lancet review is not the first to look at the effect of private ownership on the quality of care in healthcare. Last August the BMJ published a systematic review – Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality – which looked at the takeover of healthcare services by private equity funds, and found that ownership by private equity companies is associated with a worse quality of care and higher costs. This review did not look at privatisation of public-owned healthcare, but, rather a change to a different type of private company ownership, one that was focused on short-term profit.

The authors of the review, which was led by the University of Chicago, found that private equity ownership was “most consistently associated with increases in costs to patients or payers” and was “associated with mixed to harmful impacts on quality.”  Furthermore, the review identified “no consistently beneficial impacts of PE ownership.”

Taken together the two reviews provide good evidence that taking publicly-run services, such as those of the NHS, out of public hands and into the private sector is a bad move for quality of care, even if the organisation is run on a not-for-profit basis.


Elective Surgery and Patient Safety

The safety of the private sector has been a concern for many years, with questions over their lack of ICU beds, use of registered medical officers, lack of transparency, communication issues with the NHS, and even the use of individual rooms. The issue of NHS patient safety has been investigated by the Centre for Health and the Public Interest (CHPI).

The concerns include:

  • Post-operative care in private hospitals is usually carried out by inexperienced junior doctors who are working excessively long hours.
  • The consultant who carries out the surgery and who is responsible for the patient is permitted to be off-site.
  • Nature of this post-operative care has been cited as a factor in a number of patient deaths.
  • Lack of intensive care facilities means if something goes wrong then patients have to be transferred back to NHS hospitals, which in itself is very dangerous.
  • Data on patient safety in private hospitals is poor and they aren’t required to make this information public in the same way as NHS hospitals are.

With the number of patients being treated in these hospitals increasing, particularly with the Choose and Book system or with acute trusts referring patients to clear extensive waiting lists, it is important to note these issues.

CHPI conclude that NHS commissioners and clinicians would find it difficult to avoid blame, and possible legal consequences, if NHS patients are harmed in private hospitals. Particularly now that the risks are openly documented.

This raises the issue of the cost of these referrals, both in the short term and the long term. In the short term, the cost of treatment for NHS patients in private hospitals is much higher than it would be if they could be treated in NHS facilities. Moreover, if something is to go wrong and there are legal consequences then it is the NHS that may have to pick up the bill in the long term.

In another report, the CHPI also document the safety issues in private hospitals following the scandal whereby surgeon Ian Paterson wounded 500 women who underwent unnecessary breast surgery in private hospitals. They conclude that until the private hospitals have full liability for the patients under their care, then there will be no guarantee of safety.

The Paterson scandal led to a public inquiry that released a damning report in February 2020 stating that the private healthcare system he worked in was “dysfunctional at almost every level”. However, the government has yet to make the major changes in the report that would have improved patient safety in private hospitals. In November 2021, the safety of the independent hospital sector was once again under the spotlight in a report released by the HSIB (Healthcare Safety Investigation Branch) – Surgical Care in Independent Hospitals – triggered by the death of a NHS patient sent to an independent hospital for bowel surgery. The report made six safety recommendations, three to NHS England and NHS Improvement, one to NHSX, and two to the Care Quality Commission (CQC).

Diversion of money, staff and training opportunities

In February 2022, ophthalmologists warned that the safety of NHS patients could be put at risk if the private sector is given any more NHS work.

In the letter, signed by nearly 200 ophthalmologists and sent to NHS England and the Royal College of Ophthalmologists and shared with The Independent, they warned of “the accelerating shift towards independent sector provision of cataract surgery” which is already having a “destabilising impact” on safe ophthalmology provision.

They predict that the wide scale use of private providers will “drain money away from patient care into private pockets as well as poaching staff trained in the NHS.” adding that “urgent action” is needed to prevent further work being given to the private sector.

Staff who would normally do extra hours for the NHS are now being offered better paid work doing cataract operations in the private sector, but this means other eye procedures are not being carried out for the NHS and waiting times for these will grow.

Speaking to The Independent, Professor Ben Burton, consultant ophthalmologist and one of the lead signatories of the letter, said: “What’s happening is that staff who could be treating preventable but irreversible sight-threatening conditions like glaucoma, macular degeneration, and diabetic retinopathy are instead doing cataract surgery for private providers.”

The private sector is already heavily involved with the area of cataract surgery; in November 2021, the Royal College of Ophthalmologists reported that in 2016, 11% of NHS cataract procedures in England were delivered by private companies, but by April 2021 there was almost a 50/50 split, with 46% in the private sector and 54% by NHS trusts and treatment centres.

Cataract surgery is the main training ground for junior doctors, they need to complete at least 350 cataract procedures to be able to then manage more complicated work. The use of the private sector means trainees are finding it harder and harder to access the opportunities. The NHS is left with the more complex cases, which are less suitable for training. This is making it more difficult for trainees to successfully complete training and, most importantly, more difficult to develop skilled and experienced surgeons.

The issue was addressed again in December 2023, when Royal College of Ophthalmologists’ president Ben Burton told HSJ the specialty was at risk of becoming like dentistry, where patients face charges for services.

Professor Burton said a review needed to look at the entire commissioning process and argued “generous” tariff rates for cataracts were resulting in some patients with “very mild cataracts getting surgery at the expense of other patients going blind”, which he said was “just wrong”.

He added: “There is a risk that the NHS loses ophthalmology completely, like it has dentistry, in terms of it being a service which is available free at the point of delivery.

“If we are going to try and keep it as an NHS service, then we definitely need to change what we’re doing, because the current system is causing chaos, with huge financial loss to the NHS and it’s not in the best interests of patients.”

Professor Burton said the college “recognises the independent sector can help with reducing backlogs” but urged NHSE not to continue with the approach of “unplanned commissioning [which] means the NHS is losing consultants, money and trainees to the private sector”.

Further investigations into the area of cataract surgery by CHPI has found disturbing figures on the number of complex cataract operations carried out in private clinics.

CHPI found that the percentage of NHS cataracts delivered by the private for-profit sector has increased from 24% in 2018/19 to 55% in 2022/23 and over this time the NHS has paid the private for profit sector around £700 million.

The overall budget for cataract provision has doubled over this period result of this outsourcing and the percentage of the total NHS budget which is being spent on cataracts has increased from 27% to 36%. As a result it is likely that there is less budget to treat other eye care conditions such as glaucoma and macular degeneration which lead to irreversible sight loss.

Their investigations found that the rise in expenditure on cataract services has been accompanied by an increase in the number of private for profit clinics which have been established to deliver NHS cataract services. 78 new private for-profit clinics have been opened over the past 5 years.

CHPI noted that ophthalmologists they had spoken to were concerned that the growth in expenditure on NHS cataract provision is not being driven by patient need but by the commercial interests of the companies delivering them– this is known as “supplier induced demand” and is the consequence of the market driven approach to healthcare planning.

The growth in the amount of NHS cataract care which is being delivered by the for-profit private sector has also been accompanied by a large increase in the number of “complex cataracts”. The report notes that NHS England has raised concerns that the increase in the number of complex cataracts cannot be explained by changes in patient complexity. CHPI found that the provision of complex cataracts has increased by 144% over 5 years and that the increase is almost entirely due to the provision of these operations in the private for-profit sector.

The report recommends that policy makers from the National Audit Office, the NHS Counter Fraud Authority, NHS England and the Department of Health and Social Care look into the issues raised in this analysis to ensure that public money is being properly spent and to examine the wider impact of this large shift in how NHS cataract care is being provided on patients with other eye care conditions.

Facilities Management

In facilities management, there have been concerns with quality and cost. There have been reports of low-pay received by the staff employed by facilities management companies and cost-cutting leading to reduced cleanliness. An investigation by researchers at the University of Oxford found that hospitals that used outsourced cleaners had higher rates of MRSA, which causes life-threatening infections.

In 2023, cleaners and catering staff at the South London and Maudsley NHS Trust (SLaM) subcontracted to ISS went on strike due to poor pay and conditions, with some paid just £10.84 per hour. In August 2023 cleaners and caterers at Norfolk and Suffolk NHS Foundation Trust (NSFT) in Ipswich staged a protest over the “poverty wages” paid by contractor G4S. Most G4S staff at NSFT are only paid the minimum wage of £10.42 an hour, £1 an hour less than their colleagues doing the same jobs but employed directly by the NHS.

In 2013 Interserve signed a contract with Leicestershire Partnership NHS Trust, University Hospitals of Leicester NHS Trust and the Leicester City, Leicestershire County and Rutland Primary Care Trust Cluster to improve estates and facilities management services across the cities and counties. The contract was seven years long, worth around £300 million and was expected to save the NHS a significant amount of money.

However, in April 2016 this contract was scrapped four years early due to major problems and poor standards. These included patients in one hospital receiving meals up to three hours late and the merging of cleaning and catering services meaning around 100 people lost their jobs.

After the contract was scrapped, it came to light that the ex-Interserve staff were getting paid half what the NHS contracted staff were being paid.

Spin-off companies

There are several concerns surrounding this type of privatisation; these are discussed in the section entitled Spin-Off companies.


Nearly all private hospital companies carry out NHS work, two of the largest are:

Circle Health

Circle was founded in 2004. Circle was sold to PureHealth, the United Arab Emirates largest healthcare provider, in August 2023 for $1.2 billion. In early 2020, Circle acquired BMI Healthcare for an undisclosed sum.  The acquisition of BMI Healthcare, with 59 hospitals, made Circle Health the leading private hospital chain in the UK. BMI Healthcare was heavily reliant on NHS work, with nearly 50% of its revenue coming from NHS work in 2016.  The company won the contract to run Hinchingbrooke Hospital in 2011, however Circle terminated this contract in early 2015. A full company overview can be found here.


Spire Healthcare is the UK's second largest private hospital company, with 40 hospitals and eight clinics. The company was founded in 2007 and is a public company with share traded in the UK. The company's revenue is from personal medical insurance patients, NHS patients and self-paying patients. In 2022, Spire received 25% of revenue from the NHS.  A full company overview can be found here.

There are also individual profiles for leading companies including HCA International, Nuffield Health, Ramsay, Care UK.


The privatisation of hospital care has been ongoing for years. Successive governments over the last 30 years have brought in 'reforms' that have encouraged the use of private companies. The governments of Blair and Brown used private providers to bring in choice and increase capacity to bring down waiting lists.

However, it was the health and social care act 2012 that ushered in an era of competition and really opened up the NHS to private providers; the number of contracts being awarded to non-NHS organisations since 2012 has accelerated.

The NHS Support Federation's Contract reports over the past few years bring together the evidence of the increased number of NHS contracts going to private companies. These can be found on our publications page here.

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