Browne Jacobson recently hosted the fourth in its series of NHS private patient unit (PPU) roundtables, this time focusing on the insurance and indemnity landscape for NHS PPUs. 

The session brought together NHS PPU and commercial managers, insurance professionals, private medical insurers (PMIs) and other sector stakeholders to explore the complexities of indemnity cover, insurer negotiations, and the evolving relationship between private care pathways and PMI products. Guest speakers included Louise Bett, Assistant Vice-President at global commercial insurer CNA Hardy, and James Sherwood, former Chief Operating Officer at BUPA and now a consultant.

Here, we explore the key themes.

Complexity of indemnity cover for PPUs

A clear and consistent theme throughout the session was the significant complexity — and frequent confusion — surrounding indemnity arrangements for NHS PPUs. It was noted that there has traditionally been confusion over how indemnification of PPUs is managed in practice, drawing on her background in primary care from the earliest days of the Clinical Negligence Scheme for Trusts (CNST), which is managed by NHS Resolution.

A central challenge identified was that each trust is doing something different in each PPU, making standardised indemnity solutions difficult to apply. Insurance packages may need to be highly bespoke, tailored to the particular services being offered, the structure of the PPU, and the nature of the clinical relationships involved. Standard insurance policies should include standard principles clauses, but coverage will need to flex appropriately to reflect the realities of each arrangement.

Comments were made that coverage can dovetail alongside CNST cover, though where one scheme ends and the other begins is not always straightforward. This is better understood as a "wavy line" rather than a clear boundary – a graduated and context-dependent overlap, rather than a linear division of responsibility. This ambiguity creates risk for trusts and clinicians alike, particularly where assumptions about coverage prove incorrect.

The example of private providers entering the CNST in the context of the clinical negligence scheme for GPs was cited as a cautionary tale: providers assumed they were covered for all eventualities, requiring insurers to go back and revise indemnities retrospectively. Private organisations providing services within the NHS often purchase separate indemnity outside NHS arrangements regardless, with additional contracts insured separately.

Specific scenarios highlighting coverage gaps

The discussion surfaced a number of specific scenarios that illustrate the complexities of insurance coverage in PPU contexts:

• Transition from private to NHS care: A private patient who deteriorates and requires ICU-level care raises the question of exactly when they cease to be a private patient and are handed over to NHS care — and what the insurance implications of that transition are. Coverage must be tailored to reflect these possibilities.
• MRI and diagnostic services: Where a PPU is providing services such as MRI scanning within a hospital, insurance arrangements may be calibrated to activity levels (for example, based on the number of scans performed each day), creating further complexity around how coverage is calculated and maintained.
• Professional sports patients: One trust PPU director discussed anxiety among consultants regarding treating international sports players, particularly following a significant claim arising from a private operation leading to a career-ending injury (referenced in connection with Sylvan Ebanks-Blake, who won a £7m battle in the High Court against a surgeon in December 2025 after a 2013 ankle operation effectively led to the end of his career). The financial exposure has left some consultant specialists turning down this work despite having the clinical skills to undertake it. The group noted that performing such work within an NHS setting, where the full range of associated services is available, may offer a more appropriate environment from an insurance perspective.
• NHS staff performing overtime private work: Where NHS staff are undertaking private work that falls outside their NHS contract, separate insurance will be required. This is a further example of the blurring of lines between NHS and private provision.

The importance of information sharing between trusts and insurers

A recurring point was that the relationship between trusts and insurers need not – and should not – be adversarial. Where insurers can’t obtain the information they need about a PPU's activities and structure, they are forced to make conservative assumptions, which drives up costs. Greater transparency and proactive information sharing between trusts and insurers can lead to better-tailored and more cost-effective coverage.

The group identified this as a genuinely collaborative opportunity: insurers want to understand what a trust is aiming to achieve from its PPU, and with that understanding they can structure coverage to address all likely eventualities. This is a two-way process, and the message was that trusts should engage openly with their insurers at an early stage.

Structural questions: LLPs, partnerships and coverage boundaries

The session touched on structural questions arising where trusts are exploring partnership arrangements, including limited liability partnerships (LLPs). In some models, nurses are employed and paid through a separate company operating under the LLP structure. This raises the question of where indemnity coverage lies for staff who are working on NHS premises but are paid by the LLP entity.

The general position noted was that when insuring private care, insurers will typically assume that all staff involved are covered – but this assumption needs to be tested carefully and documented, to ensure there are no gaps between the type of care being provided and the coverage in place. 

The question of consultant-led PPUs was also discussed. Where a PPU is consultant-led and consultant-indemnified, different partnership arrangements that fall short of formal joint ventures can muddy the picture, with CNST coverage potentially becoming confused in the context of PPU teams. 

Participants noted a need for greater clarity about what sits within a foundation trust's own indemnity and what falls outside it. The answer, in practice, was acknowledged to vary between trusts – though the concern is that in a worst-case scenario, a gap in coverage could be discovered at the point of claim.

A further concern was raised that indemnity costs can be so high as to undermine the commercial viability of a PPU, making it difficult for a trust to generate sufficient revenue. The position of mutuals was noted as potentially distinct from that of commercial insurers – with the risk that a mutual might determine at the point of claim that a PPU's activities exceeded the scope of coverage agreed, leaving a gap.

Overview of the PMI market and implications for PPUs

An overview of the private medical insurance (PMI) market and its implications for NHS PPUs seeking to attract PMI patients brought interesting discussions. 

The single biggest shift noted in the PMI market over the past four years – and continuing – is the drive to make care digitally accessible and to orchestrate the care journey for customers. Primary care is now a core feature in all PMI products, with about 40% of people entering a secondary care journey having started within their PMI's primary care service (rising to around 70% for certain conditions such as skin conditions). 

This provides PMIs with a significant opportunity to guide the care journey from the outset, and an increasing number of PMIs are becoming more prescriptive about how they wish particular care pathways, such as in physiotherapy, to be delivered.

A growing number of open referrals are also flowing through the system, with patients approaching PMIs for recommendations on which type of consultant to see. Appointments are increasingly booked online, and there is a strong drive towards automating pre-consultation processes by exchanging data to determine whether care is covered.

Key implications for PPUs

• Nature of service matters: PPUs providing complex or tertiary care are better insulated from PMI pathway pressures than those providing services closer to the core PMI offer. A private patient admitted simply to occupy a private room within an NHS hospital is a very different proposition from a patient requiring specialist complex care.
• Unique service and scale are the twin enablers: For NHS PPUs, the two factors most likely to deliver a strong PMI opportunity are having a clear and differentiated proposition (demonstrating why the PPU is uniquely valuable to the PMI and its patients) and scale.
• Commercial viability must be demonstrated clearly: Trusts need to be able to articulate clearly why their pricing translates into a financially sustainable margin – supported by evidence such as benchmarking against NHS tariff – and to present this in terms that a PMI (which is focused on minimising costs for its customers) can engage with.
• Managing price increases: A rapid or significant price increase is difficult for any PMI to absorb if it is not forewarned. Where a material price increase is required, the advice was to phase it over multiple years and to notify the PMI as early as possible. Trusts must also accept that they carry some risk – one trust had agreed a tariff in February before the outbreak of the Iran war, illustrating the difficulty of timing.
• Consultant profiles and databases: PMIs make heavy use of the Private Practice Register (PPR) – a repository of information about consultants and their indemnity status – as well as Doctify and BUPA’s Consultant and Facilities Finder, to recommend consultants to patients. PPUs and their consultants should ensure that complete, up-to-date profiles are maintained on these platforms, including photographs, peer endorsements and patient recommendations, to achieve higher rankings and greater visibility.

Trusts were notably robust in challenging some of these points, noting that they have provided evidence to support price increases and believe they demonstrate an understanding of commercial viability. 

These contrasting views illustrate the need for closer collaboration between trusts and PMIs when considering financials, while there is potential for greater guidance on both sides. 

Opportunities and discussion points

The broader discussion surfaced several further opportunities and issues:

• Regional clustering: There was discussion of whether PPUs might cluster regionally to create a more compelling collective proposition for PMIs, potentially joining up services across a region. In many areas where group models are operating, this is something which is being looked at more closely. There are various issues to work through including any competition and Private Market Order considerations.
• Debt and PMI payment issues: Issues around debt and the management of PMI payments and debtor days were raised as a growing area of concern for some PPUs where support may be needed.

Next steps

This fourth PPU roundtable has highlighted the significant and growing complexity of the insurance and indemnity landscape for NHS PPUs, as well as the strategic importance of understanding how PMI market dynamics are evolving.

Key areas for follow-up include competition law considerations in the context of PPU collaboration, strategies for managing PMI pricing negotiations, and the development of clearer frameworks for understanding indemnity coverage across different PPU structures.

Please contact Carly Caton (carly.caton@brownejacobson.com) if you would like to be involved in future events in this series or have suggestions for topics you would like us to address.