The times are troubling for the future of the National Health Service (NHS), in the sense of a reasonably comprehensive, effective, equitable and integrated service, free at the point of use, which coordinates the efforts of public health, primary care and hospital-based services for the good of the whole population of the UK.

Before long, all of us will have to take a position, either in favour of the kind of NHS defined above or in favour of an arrangement whereby a variety of private companies compete for market share in the health sector, with the NHS reduced to handing out the money and making some show of monitoring and maintaining standards.

It is time more was said about the moves in various circles, including the Royal College of Psychiatrists, to welcome and foster an increasingly cosy relationship between those responsible for NHS provision and psychiatrists and others working in the private healthcare sector. ^{Reference Murphy and Sugarman1}

The private sector in mental health has a long history, but for many years after 1948 it was confined to a small number of private hospitals with a long pedigree, and the provision of psychotherapy. It grew significantly from the late 1980s onwards as it became clear that the much needed move out of the old system of asylum institutions had involved a miscalculation about how many people would continue to need long-term clinical care in residential settings, supported by staff who have training in the care of people with mental illness.

This calculation may have been partly due to a fantasy, based on ignorance of the realities of severe mental illness, that everyone with these conditions could be assisted to return to completely independent life in the complex place we call the community. The tragedy is that an appropriate and creative range of appropriate accommodation and support was never planned. Be that as it may, there was a miscalculation. Problems were further compounded by the increase in the prison population from the 1990s onwards.

The upshot of this is that there are now excessive numbers of people in private sector residential or hospital care because of severe forms of mental disorder. For example, in the borough where I work there are 83 people in private sector care at an annual cost of over £4 million (L. King, personal communication, 2011). Of the residents of Greater Manchester currently being treated in medium secure units, around half are in private sector hospitals. This situation has not come about, by and large, because it was found by investigation that this ramshackle arrangement would be the best way to care for this vulnerable group of people. It has arisen through the complacency of governments, the Department of Health, those working in the mental health field including psychiatrists, and health authorities. It has formed the context for the second phase of development of privately run mental health services in the UK. Private providers deserve credit at least for the insight that there was a group of people who would remain in need of care for a long period. Their other insight was to see that this could guarantee a steady and reliable flow of funding from the NHS to form the basis for significant profit-making.

A rational answer to this situation would be to plan a way out of it. This could start with an amalgamation of relevant data on a national basis, including a repeat of the audit of the ‘new long stay’ carried out on behalf of the College by Lelliott et al and published in 1994. ^{Reference Lelliott, Wing and Clifford2} Unfortunately for the private sector, such an approach would reduce the chaos on which it thrives.

The latest phase of opportunities for the private sector milking the money which most taxpayers think is going to the NHS has been developing for several years and includes venturing into the areas of drug addiction services, assertive outreach teams (in Manchester), counselling services (in Oldham) and intensive community-based care. We could, in fact, use interest from the private sector as an indicator of a need for better local or national planning in any particular area.

There are many examples of excellent and innovative work in the private sector, and at least as many in the NHS. There are also examples of bad and inhumane practice in both sectors. It is not meaningful to compare one flagship private sector provider with the NHS as a whole. The comparison should be between the NHS as a whole and the private sector as a whole, the good, the bad and the ugly.

This year’s College International Congress in Brighton featured a session on implementing growth in the independent sector. Could we perhaps get rid of the polite fiction of ‘independent’ when we mean the private sector? This sector may be independent in many ways, but it is not independent of NHS funding, nor is it independent of the wishes of its directors, shareholders or private equity backers, as, for example, even a brief examination of the recent chains of command and ownership at Castlebeck, the owners of Winterbourne Hospital, and at Southern Cross, will show. ^{Reference Brindle and Curtis3}