Keen-eyed HSJ reporters have spotted evidence of a sharp uptick in trusts’ use of outsourced (mainly “independent”) providers in England at the end of the last financial year.

The figures are tucked away in NHS England’s cumbersome quarterly reports, which retrospectively report on the deficits and the levels of spending across England’s NHS trusts. They give overall figures for spending by trusts on outsourcing, which is in addition to direct commissioning of outsourced contracts by England’s 42 Integrated Care Boards.

But as the NHS in real time reaches the end of 2023, NHS England’s quarterly figures have just come in for the final quarter of 2022-23 (January to March 2023).

As the HSJ highlights, they show an increase to £4.7 billion in spending on work outsourced by trusts to non-NHS providers, a near-doubling of the £2.4bn spent in the same quarter of 2019-20, the last months before the Covid pandemic.

However adding up all the quarterly figures for both whole financial years shows significant fluctuation within each year – and also reveals that there was only a fractional increase from £11.3bn in 2019/20 to £11.4bn in 2022/23.

Both of these two years, as we might expect, far outstripped the two Covid-influenced years 2020/21 (£6.4bn) and 2021/22 (£8.3bn).

The significant increases in Quarters 3 and 4 of the last financial year (2022/23) correspond with the increased pressure from government (and, sadly, from Labour politicians) for the NHS to make more use of private sector providers, while NHS capacity was already limited by a lack capital for investment and maintenance as well as chronic staff shortages.

A year ago Rishi Sunak further cranked up the pressure on NHS commissioners and providers to help fill up otherwise empty private beds and clinics by establishing a top-level “task force,” which we later learned was stuffed with private sector representatives. It published its so-called ‘Elective Recovery Plan’ in August.

That plan, predictably, focused on increasing the short-term use of the private sector, while lacking any longer-term vision to ensure NHS capacity can be increased to meet the needs.

By contrast (although there are some exceptions) most ICBs’ Board papers seen by The Lowdown have indicated little if any enthusiasm (in this year of tighter spending constraints) to increase the extent to which the NHS becomes more chronically dependent upon private providers – who drain both revenue and vital staff from front line trusts.

One reason for this is that private hospitals are mainly keen to hoover up low-risk contracts to deal with the simplest elective patients, leaving a weakened NHS to handle the more complex and costly caseload that remains. As NHS Providers director Miriam Deakin told the HSJ:

“more complex and time-consuming cases tend to stay largely in the hands of the NHS, while the availability of independent sector provision varies across the country.”

Moreover, as waiting list expert Rob Findlay has pointed out, ‘extra’ activity from private providers can only clear the 7.7m waiting list backlog if the NHS itself is also able to keep up with demand: and we already know that, especially in the winter months, but increasingly all year round, it can’t.

So turning to the private sector is “not genuine backlog clearance, but a way of plugging some of the recurring shortfall in core NHS capacity,” as Nuffield Trust analyst Sally Gainsbury has warned, raising  the danger of “hard wiring a larger reliance on the independent sector into our healthcare system than we had before the pandemic.”

Operation Year – Annual Total 2019 2020 2021 2022 2023
245,757 132,443 199,698 240,970 240,147

National Joint Registry

Indeed while the National Joint Registry has shown numbers of hip replacements conducted in private hospitals have increasingly outnumbered those done within the NHS, their statistics also show a net overall reduction in numbers of joint replacements since the peak of Covid pressures eased, compared with 2019. There has been a further decline in 2023 compared with last year.

In other words, use of the private sector is not increasing the numbers treated, merely ensuring that more of the cash flows out of the NHS into private pockets, rather than becoming part of the revenue stream to sustain NHS services.

It may well offer extra profits – but it’s not actually cutting the waiting list.


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