ack in that long-ago first wave of Covid-19, there really was an “all in this together” mood. People clapped on a Thursday and children painted rainbows; public trust that the government would do its best was still riding high. In those innocent days before Dominic Cummings’ eyesight test, there was goodwill towards the government. One or two early actions struck exactly the right public note. Especially this one: the NHS took over all the capacity of private hospitals, its 8,000 beds, 680 operating theatres and 20,000 staff, to carry out non-Covid emergency treatments for cancer, stroke and heart patients. In a gesture of wartime necessity, the well-off could not commandeer special treatment. But the beds were not requisitioned as they might be in wartime; they were officially bought at “cost price” and the sum has been estimated to be £1bn, steep according to many. Though other deals continue elsewhere, the contract with London’s hospitals ended in August and NHS England has since been locked in a dispute over the price of private beds. The Treasury balks at the cost, while private hospitals spy new opportunities in the spike in private demand as the NHS overflows. Private healthcare companies have seen what the Telegraph describes as a “boom” in demand; William Laing, of LaingBuisson, a private health market monitor, predicts “pent up demand” will lead to a sharp increase in NHS patients opting for “self-pay” private treatment. As deaths rise above original worst-case predictions and NHS capacity is stretched to bursting, regional clinical leaders have written to NHS England and to all the medical directors of London’s acute hospital trusts asking them not to support any of their staff who are performing non-urgent treatments in the private sector, for the next month. The Health Service Journal (HSJ) obtained their emotional letter: in conditions that only a year ago “would have been unthinkable”, they write, “it feels profoundly uncomfortable to us that some elective work that is not time critical is continuing in the independent sector. We are asking colleagues … not to support delivery of such work in the independent sector for a period of time”, until pressure on NHS services eases. The HSJ has revealed that NHS England is trying to negotiate use of private beds, especially for some 500 London cancer patients in urgent need of operations within four weeks, but currently only small, spot contracts are in place. Under the old deal, only high medical priority patients could be treated in the private sector, but now private consultants can treat any patients they wish. One signatory to the letter is Sir Sam Everington, the chair of Tower Hamlets clinical commissioning group, a GP and one of the founders of the highly regarded Bromley-by-Bow community centre, known for its pioneering social prescribing. He worries that ultimately deaths caused by failing to treat cancer, heart disease and strokes may rival Covid deaths. ”We need every bed we can get or many will significantly deteriorate,” he says. Progress is stymied in a three-way tussle: NHS England wants the beds, but the Treasury says in the summer block-booked beds went unused, while the private sector has a strong arm-twisting financial position. One of the key companies negotiating is Spire Healthcare, which was fined £1.2m last year for illegal price fixing. It is one of many private providers that have signed a £10bn deal with the NHS to clear the Covid backlog. Here’s the circularity: the private sector relies on high NHS waiting lists to attract customers. And when the NHS buys private work to cope, high waiting lists give private hospitals a double win. When the last Labour government dramatically reduced waiting times, their business dropped enormously. And let no one pretend Covid caused the present waiting list crisis, now at a historic 4.46m people in England: the number waiting in November 2019 was barely less, at 4.42m. Everington points to the weak state services pre-Covid that have made coping so difficult; not just the 100,000 doctor and nurse vacancies, but a 30% cut in school nurses leaving just one for 10 schools, threadbare health visiting and community nursing, and 112,000 care worker vacancies. The relationship between private health and the NHS has always been an awkward grey area. “Almost all their staff were trained in the NHS,” says Everington, “But there’s no payback.” He says the private sector should pay back the cost of training the nurses and doctors it uses. “I could never live with myself if I went to work in the private sector after the NHS spent well over £250,000 training me.” The other great “all in it together” symbolic gesture from the start was the pledge that all vaccines would only be available through the NHS, no paying to queue-jump. But because this is a wicked world, some will always pay their way out of queuing. Knightsbridge Circle, a private concierge club for the super rich, has already flown members out to the UAE and India on private jets for three week “vaccination holidays”. The answer to the private health dilemma has always been to build a firewall so nothing leaks, no one queue-jumps, and the true cost of everything it gains from the NHS is repaid, especially the training. The abuse of the NHS logo by private “partners” blurs the line, so patients don’t know who is treating them. The immediate answer in the greatest national emergency since the second world war is to commandeer whatever beds are needed at a take-it-or-leave-it price.