Intended for healthcare professionals


Private funding of elective hospital treatment in England and Wales, 1997-8: national survey

BMJ 2000; 320 doi: (Published 01 April 2000) Cite this as: BMJ 2000;320:904
  1. Brian Williams, professor of public health medicine (b.t.williams{at},
  2. Pamela Whatmough, research associatea,
  3. Janet McGill, research nursea,
  4. Lesley Rushton, head of epidemiologyb
  1. a School of Community Health Sciences, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH
  2. b Medical Research Council, Institute for Environment and Health, University of Leicester, Leicester LE1 7DD
  1. Correspondence to: B Williams
  • Accepted 10 February 2000

The longest delays for admission to NHS hospitals have been reduced, and hospital throughput has increased in recent years. Whether the NHS has become more self sufficient in terms of elective treatment in hospital is not known. In 1981 the proportion of elective treatments purchased privately in England and Wales was 13.2%, and in 1986 it was 14.8%.1 For 1992-3 it was 14.1% (BT Williams, JP Nicholl, unpublished data). Using the same methods as in these previous studies we compared the volume and nature of elective hospital care funded publicly and privately in England and Wales in 1997-8.

Methods and results

Information on patients admitted as inpatients or day cases during sample periods in financial year 1997-8 were obtained from 215 of 221 acute independent hospitals with operating departments in England and Wales2; data obtained included the patient's clinical status, demographic information, and source of funding for the procedure. Numbers for the whole year were estimated by weighting the sample data according to the duration of sampling, the time of year, and the number of hospitals that did not respond; these numbers were validated as previously described.3 Extracts of the latest data (for 1996-7) were obtained from the Department of Health and the Welsh Information Agency's hospital episodes statistics for waiting lists and scheduled admissions for NHS and private patients admitted for non-psychiatric, non-maternity care. Data for first consultant episodes (98% of all consultant episodes for elective patients and equivalent to the number of admissions) and data from independent hospitals were analysed using SPSS statistical software. Although these two sources of data were out of phase by a year, hospital episodes in the NHS for general and acute specialties rose only 2% between 1996-7 and 1997-8 (NHS Executive, personal communication, 1999).

Altogether 739 810 of 5 094 404 patients (14.5%) had had private funding, and 591 755 of 4 415 334 surgical patients (13.4%) had had private funding (table). One in 10 private patients were treated in NHS hospitals, and 1% of NHS patients were treated in independent hospitals. Of the private admissions, 81% were funded by insurance and 18% were funded by the patient.

Number of elective treatments (excluding abortions) according to source of funding for residents of England and Wales, 1997-8

View this table:


The proportion of elective treatments purchased privately has remained constant over nearly two decades. Although NHS patients and private patients receive a similar range of treatments the types of procedure differ proportionately. A higher than average proportion of patients pay for operations that relieve severe disability or discomfort—such as total replacement of the hip joint, which had a median NHS waiting time of 168 days in 1996-7, and lens operations for cataract (median waiting time 144 days)—and for those for which delay may increase the risk of dying, such as coronary artery operations (94 days).4 However, it is unlikely that all surgery performed privately would have been carried out on NHS patients. Procedures for which an above average proportion were funded privately included cosmetic operations for non-pathological conditions and gender reassignment. These have low priority in the NHS. The effectiveness of some other operations, such as middle ear drainage with grommets and stripping and ligation of varicose veins, is debatable, and some NHS authorities are refusing to fund them. Operations such as hysterectomy, prostatectomy, and cholecystectomy may be chosen in some instances instead of alternative, non-surgical forms of treatment. Lower thresholds for intervention apply to the use of some operations for private patients.5 Different clinical guidelines may also apply.

One of the functions of the Commission for Health Improvement is to ensure that clinical practice is evidence based. Its remit does not cover the private sector. Some health insurance companies already evaluate clinical indications for certain procedures before authorising them. Individual payers have no arbiter. The new national care standards commission, which will regulate the private sector under the Care Standards Bill, may eventually need to embrace the task of ensuring the clinical relevance of procedures.


Contributors: BW initiated the study and with LR, PW, and JM performed the analyses and drafted the paper. LR performed the sampling and weighting procedures. All authors discussed the main issues, interpreted the data, and edited the draft. BW is the guarantor for the study.


  • Funding The Association of British Insurers and the Independent Healthcare Association.

  • Competing interests None declared.


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