Waiting lists and waiting times for nonemergency health care in the United Kingdom have, as the Darzi Review put it, “ballooned.” NHS waiting lists in England reached 7.5 million as of November 2024, compared with 4.6 million in December 2019, just before the COVID-19 pandemic struck.
Reducing waiting lists and times is a top priority for the UK Government. In early January 2025, the Department of Health and Social Care and NHS England published their plan for Reforming Elective Care for Patients. It explicitly includes using capacity in the private sector to help tackle NHS waiting lists. Although the NHS has funded treatment for patients in private hospitals and other facilities for many years, this approach remains contested due to concerns about diverting scarce resources from the NHS to the private sector.
In all high-income countries, regardless of how their health care systems are funded, there is a combination of public and private sector providers. Furthermore, economic analysis suggests that what matters is how health care purchasers contract with providers and how providers are regulated, rather than whether the providers are publicly or privately owned.
Although the NHS has funded treatment for patients in private hospitals and other facilities for many years, this approach remains contested due to concerns about diverting scarce resources from the NHS to the private sector.
Discussions about the role of the private sector in treating NHS patients centers on hospital care, as most primary care providers for the NHS—GP practices, dentists, pharmacists, and opticians—have long been privately owned. The central question is whether increasing the use of private hospitals for NHS patients genuinely boosts overall capacity, thereby helping to reduce waiting lists, or whether it instead diverts staff away from NHS hospitals. There is little contemporary evidence to answer this question in the current NHS context. The need for such evidence is increasingly urgent, given rising demand pressures and only modest expectations of growth in NHS funding.
The proportion of nonemergency hospital services delivered by independent sector providers is increasing, serving both private patients and those funded by the NHS. The previous government's post-pandemic Elective Recovery Taskforce: Implementation Plan emphasised that “maximizing the use of all NHS assets and available independent sector capacity is a key part of the plan to tackle the elective backlog.” The new government concurs, stating in its plan for reforming elective care in England: “We need to use all available capacity, including in the independent sector.”
A rigorous independent analysis conducted before the COVID-19 pandemic, focusing on hip replacement operations, found that in the 11 years leading up to March 2013, private hospitals delivering nonemergency care to NHS patients increased the overall number of patients treated without reducing activity levels in NHS hospitals. In other words, private hospitals expanded total treatment capacity during that period. However, it is important to note that NHS funding was growing rapidly at the time—by nearly 10 percent annually in real terms—allowing expenditure on NHS providers to continue increasing alongside greater NHS purchasing from private hospitals.
What, then, would happen now and in the coming years if more NHS funds were allocated to private sector providers? The NHS today faces a very different situation compared with 15–20 years ago. NHS funding is expected to grow much more slowly than it did between 2002 and 2013. In its first Budget, in October 2024, the Government promised a 3.4 percent annual real-terms increase in funding for NHS England from the 2023/24 financial year to 2025/26. While this aligns with the historical average annual growth in NHS spending, it offers little additional funding beyond that.
Another crucial factor is the post-Brexit impact on workforce dynamics, particularly the movement of health care staff between the United Kingdom and EU countries. The UK health care system relies, in part, on inward migration of staff. As Professor Jill Manthorpe noted in the 2023 Annual Lecture of the Cambridge Centre for Health Services Research, 35 percent of doctors and 27 percent of nurses and health visitors in the NHS in England were non–UK nationals as of June 2023.
With only modest funding growth and a more constrained labour market, what impact will increasing NHS spending on private sector provision have?
Both NHS and private hospitals draw from the same pool of clinicians—doctors, nurses, radiographers, and other highly skilled staff. Most doctors providing private hospital treatment also work in the NHS (PDF). If private hospitals take on more NHS-funded work in future, an important question arises: will this reduce the number of patients that NHS hospitals can treat? In the longer term, both private and NHS hospitals may be able to recruit additional staff, expanding the total UK health care workforce. The number of people choosing to work in NHS or private health care settings depends on factors such as pay, working conditions, motivations, and alternative career opportunities—both within and outside health care, and both within and outside the United Kingdom.
If private hospitals take on more NHS-funded work in future, an important question arises: will this reduce the number of patients that NHS hospitals can treat?
The extent to which increased employment in private hospitals expands the total health care workforce in the United Kingdom, or reduces NHS staffing levels, is an empirical question. Research relevant to the NHS today is needed to provide evidence that can inform policy decisions in this area. As with most important policy questions, the answer is unlikely to be simple and will require careful, multidisciplinary research. Potential approaches include quantitative analysis of employment data for licensed doctors and registered nurses and midwives over time, alongside NHS workforce data and NHS and private hospital activity levels. Other promising avenues include surveys, choice experiments, and qualitative research into recruitment and retention strategies should demand for private hospital provision increase, as well as studies into how individual health care professionals might respond to shifts in the labour market.
There is an urgent need for better evidence on the UK health care labour market, including its reliance on cross-border movement. Several research pathways could be explored to address this knowledge gap. Only with this evidence can policymakers determine whether expanding private hospital provision genuinely increases the overall volume of care for patients.
