I N 2013 THE South London and Maudsley NHS Foundation Trust was approached by two Emirati investors with a business opportunity. Six years later the trust now operates two clinics in Abu Dhabi, consults at Al-Amal hospital in Dubai and is developing plans to build a new inpatient facility, also in Abu Dhabi. Altaf Kara, the trust’s commercial director, puts the mission succinctly: “The reason we are in the Emirates is to make money to meet local [ie, London’s] needs.”

The National Health Service is increasingly an international one. Although a few NHS trusts have been doing commercial work abroad since the 1970s, the number doing so has recently jumped. Deborah Kobewka of Healthcare UK , a government agency that promotes British health-care providers overseas, estimates that there are now more than 20 trusts carrying out commercial work abroad, double the number five years ago. Their jobs range from setting up hospitals to providing second opinions by video-link. The biggest markets are China, India and the Middle East.

Fame is helpful for a hospital looking to expand. The South London and Maudsley trust, for instance, runs the world’s oldest psychiatric hospital and is well regarded for having developed the “Maudsley approach” to treating anorexia, which involves the use of family therapy. To work abroad, “you probably need a recognisable brand” beyond that of the NHS , reckons Mr Kara. Some trusts are too small, too cautious, too specialised or have too much to deal with at home to work overseas.

Those that have moved abroad are proceeding gingerly. James Pool of the Central and North West London NHS Foundation Trust says that NHS standards are maintained when working abroad, and that no taxpayers’ money is on the line in his trust’s plans. It has raised its own funds by consulting and training in China. That money will now be invested in new ventures. “We’re not interested in going for maximum profits and saying, ‘To hell with the ethics’,” he adds. Another factor slowing growth is that some staff in the NHS are reluctant to provide commercial services.

Partly as a result of this caution, few hospitals have yet made much money. “No one wants an NHS trust to go rogue and start offering cheapo services just to make a quick buck,” says one hospital manager. The Christie, which runs a cancer hospital in Manchester, is advising Rongqiao Group, a Chinese property developer, on the construction of ten hospitals, the first of which is in the city of Fuzhou. Yet income from overseas work is still less than £1m ($1.3m) a year, says Chris Harrison, the Christie’s executive medical director. King’s College hospital, which has one of the largest foreign footprints, made £6m from its overseas adventures in 2017-18.