Intended for healthcare professionals


“Start private, end private”—a principle that could help protect the NHS from subsidising private care

BMJ 2024; 385 doi: (Published 24 May 2024) Cite this as: BMJ 2024;385:q1155
  1. Alastair D Hay, professor of primary care, Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol
  1. alastair.hay{at}

With public satisfaction with the NHS at its lowest,1 the increasing use of private healthcare is concerning.2 The number of UK adults estimated to have health insurance doubled between 2021 and 2022.3 A YouGov survey conducted in April 2023 found that one in eight people in the UK reported using private healthcare, and one in four considered using private healthcare in the previous year.4 Of those using it, a third said that it was for the first time.4

The relationship between the NHS and private healthcare sector in the UK is complex. Arguments in support of private provision emphasise taking pressure off the NHS and promoting choice for those who have the means to pay for healthcare.

As an NHS GP, I am not convinced. The state pays a premium to train staff and provide a 24 hour, 365 day healthcare service. This means that anyone can access the care they need, when they need it, however inconvenient (or expensive). And while private healthcare is seen as an entitlement in a free market state, experience tells me that money and health do not mix well. It is too easy for a private provider to put profit ahead of patient wellbeing, selling tests and procedures that are unnecessary or not in the best interest of patients. Importantly, private tests need interpreting, procedures need explaining, and complications need treating. This work is often picked up by the NHS.5

The “start private, end private” principle would require the costs of follow-up NHS care be included upfront when private healthcare is purchased. They could be estimated as an average per procedure and passed from the provider to the NHS in the form of an NHS tax, similar to how the UK government recovers value added tax (VAT).

While some of these costs are known, many would require more precise estimation. For example, we know that 10% of people having hip replacement surgery will experience infection, deep vein thrombosis, pulmonary embolism, fracture, or require re-operation within six months.6 And a further 34% will experience joint stiffness, pain, swelling, nerve damage, and infections of the respiratory and urinary tracts.6 But a more precise cost estimate would need to be calculated by determining the frequency and cost of each event per hip replacement surgery.

Similarly, follow-up care cost estimates would be needed for patients attending private “health screening” clinics, patients having cosmetic procedures, and patients purchasing point-of-care tests (POCTs) for use at home.

POCTs are a particular concern. Increasingly available via the high street and internet, POCT use was mandated in the pandemic, and they are now widely accepted by the public. The POCT industry is expanding rapidly, and its global market share is predicted to exceed $50bn by 2028.7 Commonly purchased products include tests for blood glucose, haemoglobin, strep A, chlamydia, covid-19, influenza, urinary tract infections, and genetic testing, with some results available in as little as five minutes.

I predict that GPs will receive increasing numbers of requests from patients wanting help interpreting POCT results. And the resulting consultations will be difficult, requiring time to explain false positive and false negative results, and that many POCTs are inaccurate and not evidence based. Abnormal results cannot be “put back in the bottle” and the resulting anxiety could lead to patients demanding remedial action, placing pressure on doctors to request further tests and treatments. Well intentioned medical reticence could be misinterpreted as “the doctor not taking the patient seriously” or “trying to save NHS money.” And the ensuing care could cost hundreds if not thousands of pounds, perhaps involving multiple GP consultations, blood testing, radiographic imaging, and specialist referrals.

The “start private, end private” principle proposes three mechanisms that could help protect the NHS from providing unquantified, increasing subsidies to the private sector.

First, all private healthcare activities, including POCTs, should be regulated and all post-test or procedure healthcare costs quantified. Where the NHS is expected to provide this care, it should be added upfront to the cost of the test or procedure when purchased and automatically passed to the NHS. This could be done in parallel with the systems currently used to collect VAT. If the NHS is exempted, it should be made clear to the patient that their private provider is responsible for this care, and these costs.

Second, urgent action is needed to strengthen existing regulations for POCTs.8 Currently, manufacturers need only demonstrate a POCT is “equivalent” to a standard laboratory test. As with the pharmaceutical industry, the Medicines and Healthcare Products Regulatory Authority should require manufacturers to produce robust evidence of clinical and cost-effectiveness and to quantify harms. Tests (and procedures) without this evidence should be clearly labelled, and potentially banned completely.

Finally, before any test or procedure, private providers should be mandated to give patients clear information regarding the benefits and harms of care. This should include information that tests are not 100% accurate and that many will identify health “problems” for which treatments may not be available or appropriate.

The NHS requires concerted support and protection to prevent its collapse. The NHS currently provides a safety net for the follow-up of patients receiving tests and procedures in the private sector, often at great inconvenience and expense. The predicted expansion of the private sector will only add to these costs. In my opinion, the private sector (insurers, hospitals, clinics, private screening companies, POCT manufacturers) should be responsible for covering these costs in full, which should be quantified and included upfront within the price of the test or procedure at purchase by the patient and passed to the NHS as appropriate.


  • Provenance and peer review: not commissioned, not externally peer reviewed.

  • Competing interests: none.