The independent mental health sector is probably positioned where the acute sector would like to be: with a significant proportion of its income coming from the NHS and long-term working arrangements, if not agreements, in place.
And it is booming.
Independent healthcare analyst William Laing says 65 per cent of the revenue of acute independent psychiatric hospitals comes from the NHS - a spend of£161m in 1999-2000 - up from£104m the year before.
In some areas of work, the independent sector is the major provider for the NHS - it provides more than half the medium-secure places in the country, for example, and is a major supplier of substance misuse and eating disorder treatment.
Yet the 86 hospitals providing acute psychiatric services are diverse. There are a few big players - the Priory group and Partnerships in Care from the for-profit sector and also the charitable St Andrew's - but also many smaller groups and stand-alone units, often specialising in one area.
'Rather ironically, the concordat did not include mental health, ' says Westminster Healthcare chief executive Dr Chai Patel. But he points out trust managers are now freer to use spare capacity wherever it is - and that is to the benefit of independent providers.
Most work is still on an ad hoc basis but the major players are trying to develop longer-term relationships and ultimately long-term contracts. As many independent players specialise in niche markets where the average district general hospital may only see a handful of patients a year, the development of regional specialist commissioning groups has been significant.
James Watkins, the director of strategic development at St Andrew's, says before these groups developed the hospital had to deal with over 100 commissioners. Now there are nine groups in England and Wales, with more predictable needs and knowledgeable staff.
This is encouraging longerterm working and increased planning of facilities. 'Our experience at St Andrew's is that the closeness of our relationships with our NHS colleagues is improving, ' says Mr Watkins.
That is a view echoed at Partnerships in Care. But managing director Peter Farrier says, despite the close working with commissioners, there are no long-term contracts in place though there have been discussions on the lines of service-level agreements.
So is the future rosy?
Certainly, NHS spending looks set to continue increasing but changes are coming. One concern is what will happen to specialist commissioning when the NHS regional offices disappear and the number of health authorities drops from 90 to 30.
The NHS is also likely to develop more of its own facilities for medium-secure patients - where there is general underprovision - and some of the non-NHS providers may look to the even more specialist areas of women and adolescents who need medium-secure facilities, and possibly long-term lowsecure provision for former special hospital patients.
Mr Farrier says the aim is always to complement what the NHS does. He identifies provision for women as a critical area for the future, pointing out many women have been inappropriately placed in the past.
Provision is becoming more specialised, using staff - especially psychiatrists - with expertise and knowledge in one area of psychiatry rather than across the board. 'It is no longer appropriate to have a general psychiatry ward - there are more specific needs.'
But Dr Patel does not rule out greater involvement in a wider range of psychiatric services. 'It depends on the goals of the trust, ' he says.
'When you bring in an outside supplier, you have to be clear about the goals.'
Priory Healthcare (owned by Westminster but now up for sale) Size: 1,200 beds in 16 psychiatric hospitals, two rehabilitation hospitals and a number of smaller units.
Value: NHS work is valued at£55-60m - about half overall revenue.
Distinguishing features: public image is of celebrities hopping in and out for drink and drugs treatment, but typical patient is more likely to be a middle-aged stroke victim or adolescent with anorexia. Treats a range of psychiatric disorders, including addictions, post-traumatic stress and eating disorders, and is particularly strong on care for adolescents. Expanding in secure accommodation field.
www. prioryhealthcare. co. uk Partnerships in Care (owned by General Healthcare Group) Size: 14 units with 650 beds Value: almost all work is publicly funded, either through the NHS or social services.
Distinguishing features: houses more than half the patients detained under the Mental Health Act outside the NHS, and has around 20 per cent of the country's medium secure places. Known for high quality work with difficult and needy patients.
www. generalhealthcare. co. uk St Andrew's Group of Hospitals Size: 575 beds in three locations Value: turnover was£55m in 2000-01. Exact figures for NHS work not available but almost all work in its core services is funded by the NHS. Around 100 beds are run as a joint venture with a private sector partner and have lower NHS usage.
Distinguishing features: charity with long history of close working with the NHS. Most services on single site in Northampton. Now specialises in medium-secure placements (including adolescents) and patients with brain injuries. New joint venture with Cygnet Healthcare provides services in general acute psychiatry, eating disorders and addiction.
www. stah. org