Long-term relationships between the NHS and the independent healthcare sector may still be rare - but they can bring benefits for all sides.
Some of these benefits are obvious - an income stream for the private sector and patients successfully treated for the NHS. But many managers also point to less tangible benefits, such as better working relationships and greater mutual understanding.
So what do partners look for when going into a contract - and what makes a publicprivate arrangement successful?
'We are looking for something which enables us to find another income stream to complement the businesses we are currently operating, ' says operations director Richard Jones, of BUPA. 'What we are looking for is reliable relationships and a way of using some capacity we would struggle to fill. It has to be a viable proposition and make commercial sense.'
Many existing arrangements are relatively small, albeit beneficial. In Windsor, for example, the BMI Princess Margaret Hospital has 'rented' sessional use of a scanner to the NHS for 10 years. Currently, 3,500 NHS patients are scanned a year at a cost of£80,000. Rosie Faunch, executive director of the hospital, says they invested£2m in a new scanner two years ago - an investment which the local trust would not have been able to make itself.
Equally, BMI gets a substantial payment each year for making use of time when the scanner would otherwise be idle.
A number of BMI hospitals operate on NHS property, sometimes with a physical link to an NHS hospital. At St Peter's in Chertsey, for example, a 52-bed BMI unit is linked to the main hospital by a glass corridor.
BMI pays the hospital for the 'right' to treat its private patients and also pays for pathology, pharmacy and some other non-clinical services. Unusually, the trust also receives payment if any private patients have to be transferred to the NHS for particularly complex care.
St Peter's has also used some of the private hospital's beds, paying on a per night per patient basis at a favourable rate. It is now looking at using the hospital more extensively for a waiting-list initiative.
Mark Jennings, director of support services at Ashford and St Peter's NHS Hospital trust, says the arrangement has worked well - partly due to good lines of communication between the two sides. There is a joint management board for the BMI unit, including representatives of the trust and hospital consultants.
The arrangement has lasted for a decade but Mr Jennings points out: 'You can't foresee what the NHS is going to do when you go into any of these long-term commitments. So far, our arrangements have been flexible enough to cope.'
It is also important to choose an experienced provider, he suggests.
Mark Britnell, chief executive of University Hospital Birmingham trust, also stresses the importance of working relationships. His trust has used the BMI Priory Hospital for cardiac operations for two to three years and expects this to continue for a similar length of time. He commits himself for up to a year ahead, allowing the Priory to plan the use of spare capacity.
'The more work I can give them, the better the rate for me, ' he says. 'With the national plan, I can see myself signing a two-year agreement within the next 18 months.'
Private providers also have to deal with the vagaries of the NHS. Melvin Robson, general manager of the BUPA Hospital in Portsmouth, has recently won several contracts with local trusts and a contract with the Ministry of Defence, placed with BUPA nationally. He says the NHS can take a long time to decide to place a contract, but then wants it done quickly. He now uses a template contract and ensures that once a decision has been made, his staff can move as quickly as possible.
There are probably more long-term agreements emerging in the nursing home sector than in acute care - and as the NHS starts to fund some nursing care, these are likely to multiply. Arrangements can be especially complex, involving social services and several health agencies.
Ashbourne Homes has been involved in a number of long-term projects.
Intermediate care development manager Valerie Smith says every area will have different needs, and it is important to respond flexibly to that.
Where multiple agencies are involved, a steering group on which everyone is represented can help to thrash out problems.
'One difficulty is where there is not a single gatekeeper.
There can be confusion about people referring inappropriately, ' she says.
BUPA has made agreements to provide intermediate care and rehab beds in a number of areas. Typically, these agreements may be with the local authority but the health authority, primary care trust or hospital trust will be involved in planning, and sometimes staffing, the units.
In Bromley, where BUPA runs some council-owned care homes, an 11-bed rehab unit runs within one of the homes. An NHS-employed occupational therapist and physiotherapist work alongside BUPA care staff.
Des Kelly, partnerships director of BUPA, says the arrangement has worked well but has not been without tensions. 'The line management arrangements are different for the healthcare professions and the other staff in the home. Generally, the decision to admit rests with the home manager but, in this case, it is with the occupational therapist who manages the unit.' This gives rise to some disagreement over who will be admitted.
Staff also need to understand the different roles of the occupational therapist and physiotherapist, who are likely to emphasise the importance of patients doing things for themselves and building confidence, rather than carrying out tasks for them.
Mr Kelly says: 'With the advent of care trusts, where HAs and local authorities are going to be working more closely together, it seems to be a logical extension of what we are doing.'
Home from home: preventing inappropriate hospital and nursing home admissions Three-way working between social services, the health system and a private care home have improved services for people needing rehabilitation and assessment in Bromley.
For the past 18 months, 12 beds have been designated for rehabilitation and assessment in an existing privatesector nursing home - Lauriston House, part of the Ashbourne Homes group. Social services pays for care while NHS-employed therapists, and a visiting GP and consultant, are funded by Bromley primary care trust and before that, Bromley health authority.
Patients typically stay in the unit for four to eight weeks to avoid inappropriate admissions to both hospitals and nursing homes and to prepare for a more independent life after a hospital stay. Often, they have been cared for at home but are suddenly thrust into a crisis - for example, because their carer leaves or dies.
The unit is now running very smoothly but it has not always been an easy ride, according to Carol Brooker, who manages continuing care for Bromley PCT.
She stresses the importance of selecting the 'right' patients - the unit now will not take people with severe dementia after one or two placements did not work out very well.
'Be really clear about what you are trying to achieve. Even though everyone knows what you are talking about, you need to have it very clearly documented, ' she says.
Valerie Smith, Ashbourne's intermediate care development manager, agrees that precision is important. 'I think if we were to do it again we would be clearer about what everyone's input is.'
But there have been positive moves forward as a result of the Lauriston House experience. For example, spare capacity in the unit was used to cope with delayed hospital discharges at Christmas and the public sector partners are now likely to become involved in recruiting a senior member of staff for the whole home.
The scheme has also tried to give all the staff working with patients insight into the whole process - staff from the home went into hospital to talk to nurses there, and hospital nurses have been to the home to see what can and can't be achieved with patients. This greater understanding can ensure that patients are placed appropriately.
Despite teething difficulties, the scheme was reviewed after a year's operation and has now been extended for another two years.
Early learning: partnership working in paediatrics When the Manchester Children's Hospital trust hit problems with waiting lists in 1999, it turned to a local private hospital for a solution. But what was intended as a short-term arrangement has continued and brought benefits to both sides.
Around 30 to 50 children a month now undergo elective surgery at the BUPA Hospital Manchester, funded by the NHS. The children are screened in advance by the trust as the hospital has no paediatric intensive-care facilities The benefits for the BUPA hospital have included better recruitment of specialist children's nurses. It now has six full-time RSCNs, two nursery nurses and shares a play leader with the trust. 'If we only had a couple of tonsils coming through each week, it would not keep their interest up, ' explains hospital matron Sandra Saleh.
The BUPA hospital has also been able to 'police check' staff through the trust, which has speeded up a process which can take three to four months for units outside the NHS. According to Sandra Saleh, problem areas have been few: there were difficulties in staffing theatres last year and at one stage sharing theatre staff was discussed, though this was not put into operation.
The hospital has also had to monitor 'do not attends' - a rare occurrence in the private sector but common in the NHS.
A looming difficulty for private hospitals doing children's work is proposals from the Independent Healthcare Association that paediatric resident medical officers should be on duty while children are inpatients. 'That will impact on us - we have to find them and have to pay them - so we need enough patients going through to make it worthwhile, ' says Sandra Saleh.
And another factor is how private patients react to sharing facilities with NHS-funded patients. Sadly, in Manchester there have been some adverse comments.
Top tips for a successful marriage . . . from those who have gone before.
Be honest with each other and do not try to hide problem areas.
Keep lines of communication open - regular meetings allow all sides to discuss both progress and problems.
Try to understand the other partner's position and what they want from the relationship.
Patient selection is important, especially where a private unit has limited facilities to deal with a 'crash'.
Be specific about what is expected from a partner and what you will provide.
Rome wasn't built in a day. . . and contracts between the NHS and private sector certainly will not be.