Labour’s new NHS elective reform plan for England has developed against a backdrop of expanded waiting lists emerging from the COVID-19 pandemic and reduced NHS spending. A key aspect of the plan relies on the right of NHS patients to choose an NHS or private provider for their NHS-funded treatment enshrined by the NHS Constitution since the days of New Labour. This in turn relies on a new agreement between the NHS and private healthcare providers.
This proves controversial because NHS-private healthcare interaction – which has existed since the NHS’ start in 1948 – creates a “two-tier” health system. Indeed comments by the Secretary of State for Health and Social Care, Wes Streeting MP, appear to make virtue of necessity: “If the wealthy can choose where and when they are treated, then working-class patients should be able to, and this Government will give them that choice”.
This use of patient choice policies – where choice can relate to a first consultant appointment, faster treatment, or tests – appears to aim at redressing the balance between the NHS and private healthcare. While less use of private healthcare was noted during the COVID-19 pandemic and the 2008/9 economic downturn, record numbers of patients “going private” were observed recently, to the point that the Joseph Rowntree Foundation included health budgeting as part of minimum income requirements for the first time in 2024.
Patients before ideology
The Prime Minister, Sir Keir Starmer, has said he is “not interested in putting ideology before patients”. It seems clear that “ideology” here aims to counter criticisms of “NHS privatisation”, and that the Labour government is echoing New Labour, which demarcated its approach to NHS-private healthcare interaction as separate from that of the Conservatives.
Nevertheless, both parties are forced to contend with the concession of allowing consultants to continue private practice alongside their NHS workload which enabled implementation of the National Health Service Act 1946. Whether this represents a weak spot or a strength hardwired into the system remains a topic of debate. Certainly the lack of mainstream political appetite to undertake radical NHS reform (whether to reinstate its former fully public status, or to refocus its existence relative to private healthcare) means that more recent attempts at radical reform of the NHS have failed.
What remains is a middle ground of compromise which utilises NHS-private healthcare coexistence to underpin patient choice policies since the early 2000s.
But what do patient choice policies look like across England in the 2020s? Does an NHS patient living in say Norfolk, London, or Liverpool have the same choices? The Competition and Markets Authority has long framed London as the main location for private healthcare, which may suggest a North-South divide, or overlook rural areas.
Mapping patient choice policies in England
I have been leading research into mapping patient choice policies across England in order to better understand how and where the private healthcare market functions for NHS patients. To do this, we analysed publicly-accessible NHS Digital Monthly Referral Return data between June 2020 and March 2024, a period which started with the end of the first national lockdown so offered a unique “re-set” moment.
This data covers referrals by GPs or other providers (such as optometrists) for a first, consultant-led hospital appointment. It allowed us to identify, and track activity by, private provider groups, such as Spire and Ramsay. These groups treat NHS patients across all seven NHS commissioning regions of England, as well as private patients. Our findings also confirm that a core set of private provider groups which signed the “major deal” for the COVID-19 response have continued their NHS work.
Initial findings suggest that approximately 90-95% of NHS patient referrals were to NHS providers across England. The South East initially saw the most referrals to private providers (5-10%), but by late 2022 was being substantially overtaken by the North East and Yorkshire, which saw 14% in March 2024. London appears an outlier with only 3% of referrals to private providers in March 2024. From this initial mapping it is possible to review geographical differences by specialism based on waiting list data.
The small number of NHS patient referrals to private providers is typically explained in terms of patients not knowing about their right to choose. However, other factors likely also come into play, such as the evolution of private healthcare market to treat different conditions, and who makes the referral. The inclusion of data from SpaMedica, the largest provider of NHS cataract surgery, which typically sees referrals from optometrists such as Boots or Specsavers rather than GPs, may explain the increase in NHS patients being treated by private providers in the North East and Yorkshire.
From a two-tier system to three tiers?
With Labour’s focus on empowering patients, and ramping up use of the NHS App to support the elective reform plan, there is a real risk that three tiers emerge within the English healthcare system.
The first tier involves patients “going private” and paying for treatment, thus opting out of the NHS.
The second tier may relieve pressure on the NHS by certain NHS patients selecting a private provider on their smartphones and driving for treatment. This tier appears to form the focus of 2022 research by the Patients’ Association and Independent Healthcare Provider Network, as the benefits of patient choice are framed in juxtaposing reduced waiting times with limited drive times.
A third tier then emerges for those NHS patients who depend on the NHS because they may not have access either to smartphones or to private transport, so may be relying on opaque initiatives such as the Healthcare Travel Costs Scheme alongside difficult-to-access benefits. This is where the plan’s commitments to addressing health inequalities will be tested.
Labour recognises that not all NHS patients will want to choose, but it is this third tier which needs most attention in implementing Labour’s elective reform plan to demonstrate recommitment to the NHS’ founding principles of healthcare access based on clinical need, not the ability to pay.
Please note that the research outlined above is currently still in development.
(C) Mary Guy, 9 January 2025.
Add comment
Comments