• Multiple trusts with active private units continue to offer treatments
  • Providers argue it keeps the revenue in the NHS
  • NHS England and partners reiterate ban on offering restricted procedures privately
  • NHSE says it thinks most trusts are not offering them

Hospital trusts are continuing to allow patients to pay to have procedures which are banned or tightly restricted on the NHS, sparking a protest letter from NHS England.

Rules introduced on 1 April by NHSE mean four operations are banned on the NHS except in very rare cases with special permission, and a further 13 are highly restricted. This is on the basis that “the evidence shows that in most cases the benefits don’t justify the risk and opportunity cost involved”, although patients and families are often keen to receive them.

The four procedures with the most severe restrictions are: surgery for snoring (where no obstructive sleep apnoea), dilatation and curettage for heavy menstrual bleeding, knee arthroscopy with osteoarthritis, and injection for nonspecific low back pain (where no sciatica). The 13 others include breast reduction, removal of benign lesions, and grommets for glue ear in children - the full list is below.

NHSE guidance from November, developed with the Academy of Medical Royal Colleges and the National Institute for Health and Care Excellence, stated that because of concern “some patients may seek to get access to these treatments privately even if they are not appropriate… we do not expect NHS providers to offer these interventions privately”. 

However, HSJ looked into the small number of non-specialist trusts which have relatively large private patient units, and found nearly all were continuing to offer the treatments. 

NHS England this afternoon responded to the issue by warning all trusts: “We do not expect NHS providers to offer these interventions privately.”

Three foundation trusts - King’s College Hospital, Chelsea and Westminster, and the Royal Surrey - said they were continuing to offer the procedures as before 1 April. A further three - Frimley Health, Imperial College Healthcare and the Royal Free - are advertising several of the procedures on their private-facing website. Asked about it, none of them wanted to comment further.

Ahead of the NHS ban, relatively few patients were having the procedures done privately at trusts, with limited income. Figures given to HSJ show King’s, Chelsea and Westminster and the Royal Surrey did a few dozen each in 2018-19. 

But many trusts - under huge financial pressure - have looked to expand private units to generate income in recent years. 

After being contacted about the issue by HSJ, NHS England today issued an email to trust chief executives and medical directors, restating its guidance.

The email, jointly signed by Professor Stephen Powis, national medical director for NHSE and NHS Improvement, and leaders of the Academy of Medical Royal Colleges, NICE and NHS Clinical Commissioners, said: “[NHSE and NHSI] expect NHS trusts to be evidence-led in everything they do… The guidance therefore also makes it clear that we do not expect NHS providers to offer these interventions privately.”

It points out the Care Quality Commission has agreed to monitor “compliance… through regional assurance processes and CQC inspections”.

NHSE and I say “indications suggest the vast majority of trusts are in compliance with this guidance” but asks trusts to “consult with your teams and confirm that your organisation is in full compliance”.

The email indicates the restrictions programme, called “evidence-based interventions”, will be expanded later this year.

Blackburn with Darwen director of public health and wellbeing Professor Dominic Harrison, who has raised the issue, said: “It is critical to avoiding further inequalities in health that clinical commissioning groups and NHS trusts follow NHS England’s policy… NHS trusts should not be using NHS resources of staff, equipment or buildings to offer private treatment for the rich which  have been deemed inefficient, ineffective or of ‘limited clinical value’ for the poor.

“Rising demand means that the NHS is clearly having to ration its services to focus on those that are most life-saving. If this is fair at all – it is only fair if it applies to us all.” 

However, NHS Providers chief executive Chris Hopson said: “There are some procedures people may quite reasonably want to consider which may not be available on the NHS in that area because of commissioning decisions.

“In those circumstances, some will turn to the private sector. We know that a lot of patients would prefer to have such treatment done at their local hospital, which they know and are used to which is why some trusts offer that opportunity. The revenue generated can be kept within the trust and then used to support work carried out for NHS patients.”

Hugh Risebrow, a management consultant who works on NHS-private partnerships, said: “Most low complexity procedures are done in private hospitals rather than NHS private patient units. But if the NHS has decided these are not good value, and patients are still free to choose to have them done, the logic of the NHS restricting where they can be done privately is unclear.”

Last month Warrington and Halton Hospitals Foundation Trust had to “pause” a scheme baldly promoting private-pay treatments to patients, indicating they were not available or would face long delays on the the NHS. These included some treatments which are restricted nationally from 1 April, but several which are not, such as hip and knee replacements.

Restricted interventions

Category 1 - only available in “exceptional circumstances” - target to reduce ops by 95 per cent.

Intervention for snoring (not OSA)

Dilatation & curettage for heavy menstrual bleeding

Knee arthroscopy with osteoarthritis

Injection for nonspecific low back pain without sciatica

Category 2 - patients must “meet agreed criteria” - target to reduce rate to bottom quartile.

Breast reduction

Removal of benign skin lesions



Haemorrhoid surgery

Hysterectomy for heavy bleeding

Chalazia removal

Shoulder decompression

Carpal tunnel syndrome release

Dupuytren’s contracture release

Ganglion excision

Trigger finger release

Varicose vein surgery

Updated 8.30am on 9 July to include Dominic Harrison’s comment. Updated at 1.30pm to include list of the procedures affected.