Essential insight into England’s biggest health economy, by Ben Clover.

Once again, London specialists dominate the list of trusts earning the most from their private work.

As usual, the Royal Marsden Foundation Trust came out on top with an income of £121m for 2018-19, a 16 per cent increase on the previous year.

The trust said it had achieved this through “increased capacity”, particularly imaging and robotic surgery.

The trust, which operates from Chelsea in central London and Sutton in the suburbs, has long been a special case. It was granted special dispensation in the Labour era to exceed the private patient turnover cap that FTs were subject to.

Private income now represents more than a quarter of its overall income.

But across all the London trusts earning significant amounts from private work, separating turnover from actual profit is difficult (and, as they say in the business world, “turnover is vanity, profit is sanity”).

There is a view that any private provision of healthcare is bad and NHS trusts offering it is sinister. In practice it is more complicated than that.

The medics at top London teaching hospitals often have large private practices, so does it not make sense for the NHS to let them do that work at the same place as their day job, reaping the benefits?

It probably depends on their job plan. If it’s their own time, then why not? If a consultant’s NHS time is being spent doing private work for the benefit of the NHS trust, then it’s slightly harder to make the case.

But even then it might make sense if it helps retain a key member of staff, while bringing in private income for the trust.

What is more difficult to justify is significant amounts of NHS-funded time going on treating private patients while NHS waiting times spiral (and most of them are).

Either way, the Marsden’s private sector success is such that it is considering opening a new facility to offer a broader range of treatments in central London.

The decisions of NHS commissioners are obviously pretty consequential for the private sector in health, even for cancer.

For example, NHS England’s decision not to commission proton beam therapy for prostate cancer seems to have been a big factor in the development of the Rutherford Cancer Centres.

The company has four centres and does offer this service, with prostate being the most common cancer in men.

As this country gets poorer and barring some miraculous step change in funding, the difference in outcomes for cancer between rich and poor will probably only get starker.

This is most likely to manifest itself not so much in the treatment of cancer but in the diagnostics.

You run into obvious equity issues if wealthy people can afford a private scan and then start NHS treatment before poorer people have even had their scan.

Delayed diagnosis is probably the biggest single contributor to the UK’s not-great cancer outcomes overall.

There has been more investment promised but the public in the main don’t realise how bad the situation is on cancer diagnosis, and how stark the variations.

The recent Cancer Research UK report on the staffing crisis in diagnostics used Public Health England data on what stage people had their cancer diagnosed at. The proportions picked up at stage four (the worst possible, often too late) ranged from 34 per cent in parts of the East Midlands to 21 per cent in commuter belt Surrey.

Of the London clinical commissioning groups, Bromley had the best results on this measure – which makes sense in one way, as it is a wealthy outer London borough suburb – but in another it is perhaps surprising given a lot of its scans will have been carried out by King’s College Hospital FT, which has had significant problems with diagnostics in recent years.

Of Bromley’s cancer diagnoses, 23 per cent were detected at stage four. In neighbouring Greenwich, 31 per cent of patients were detected at this late stage.

Greenwich is more deprived, sure, but is it that different to City and Hackney’s population, which managed a performance on the 2017 data only slightly worse than Bromley?