Lothian LMC / analysis & debate
Analysis
Something is shifting in how the country talks about, and uses, private healthcare. This analysis doesn’t argue that the shift is good or bad. It argues that it is real, that it is measurable, and that general practice — sitting at the gateway of the NHS — needs to understand it and start thinking about what it means.
This is not a hypothetical trend. Polling for Healthwatch published in March 2026 found that nearly one in seven people had used private healthcare in the previous year — almost double the proportion of just two years earlier — and that long NHS waits had overtaken perceived quality as the leading reason for going private. Private medical insurance now covers more adults than at any point in over 25 years, driven substantially by employers adding it to salary packages. The UK has recorded the fastest growth in spending on private insurance and out-of-pocket healthcare of any G7 nation.
The shift extends well beyond hospital treatment. Private ADHD and autism assessments, self-pay diagnostic scans, weight-loss medication obtained through online prescribers, “health MOT” packages and subscription wellness services have made paying for healthcare a routine consumer behaviour for a growing share of working-age adults — often people who would never think of themselves as “private patients”. Every practice in Lothian sees the downstream effects of this in its inbox.
It is worth knowing that the trend has a name inside the private sector — and it is the same word a sceptic would choose.
“This positivity around the private market can be seen in light of the growing ‘normalisation’ around paying for treatment…”
Independent Healthcare Providers Network, industry barometer, 2026
The private sector’s trade body reports rapidly growing confidence in the self-pay market and describes public willingness to pay as a normalisation that is “becoming ever more apparent”. Whatever one concludes about intent, the sector recognises the shift, welcomes it, and is investing on the assumption it continues. Media coverage that presents going private as an unremarkable consumer choice — comparison pieces, “how to skip the queue” features, sponsored content — both reflects that reality and reinforces it.
Public attitudes contain a tension that any serious analysis has to hold onto, because it points in two directions at once.
Commitment to the founding principle remains overwhelming and stable — proposals for user charges and insurance models have been repeatedly tested with the public and rejected, and the American model is rejected across the political spectrum, including by a clear majority of Reform voters. Yet a large majority simultaneously expects the principle to erode, and a rapidly growing minority is quietly acting on that expectation. People can believe in a principle and plan for its failure at the same time. Expectation of erosion may matter as much as support for the principle, because people rarely fight for what they have already priced in losing.
The framing of political debate has shifted in a few short years: from arguments about funding levels, to a governing description of the NHS as “broken”, to an official injunction that it must “reform or die”. Think tanks now argue openly that the public is ready for “serious reform” drawing on mixed European models. One major party’s platform has included tax relief on private healthcare and vouchers for private treatment, and its leader has said over more than a decade that Britain will have to consider insurance-based funding — while standing on manifestos promising care free at the point of use. None of the major parties proposes charging. But the range of things it is possible to say out loud — what political scientists call the Overton window — has visibly widened.
It is tempting to read all this as a coordinated softening-up exercise. The evidence supports something subtler and arguably harder to counter: a self-reinforcing cycle in which nobody needs to intend the outcome for the outcome to arrive.
The normalisation cycle
Each step is individually rational — for patients, providers, employers and politicians. The cycle as a whole changes the system without anyone deciding to change it.
The economist Albert Hirschman described the underlying dynamic decades ago: when people can exit a struggling service, they stop using their voice to improve it. Richard Titmuss added the warning that most concerns the NHS specifically: services used only by those who cannot leave tend, over time, to become poorer services — because the people with the most political and economic weight no longer depend on them. Neither observation requires bad faith from anyone. That is precisely what makes the dynamic durable.
It is important to state the case on both sides, because both are made in good faith.
The safety-valve reading. Private capacity relieves a system under intolerable pressure. Every self-funded operation is one the NHS does not have to perform; patients regain function and return to work sooner; nobody is harmed by another person’s choice to pay. On this view, the growth of private care is a symptom being managed, not a disease progressing — and it buys time for NHS recovery.
The ratchet reading. The two systems draw on one workforce, so private growth quietly transfers clinical capacity away from NHS patients. A two-tier pattern of access hardens into a two-tier pattern of expectation. The political constituency for NHS funding weakens: those who go private keep paying for the NHS through tax, but no longer depend on it — and people who feel they are paying twice tend, over time, to press less hard for NHS improvement and to become more receptive to arguments for a smaller state role. And international evidence gives little comfort that the destination is better: systems where charges and insurance play a larger role tend to cost more overall without delivering better outcomes.
If drift continues, the realistic destination is not the American model — which remains politically rejected across the spectrum — but something closer to the European mixed systems, arrived at not by decision but by accretion: each step small, each step reasonable, no step ever put to the public as a question. Whether that would be acceptable is a legitimate debate. The concern of this analysis is narrower: that it is currently happening without the debate.
General practice is the part of the NHS where this shift is felt earliest and most concretely. Practices absorb the unfunded downstream work that private episodes generate — the requests for blood tests, monitoring and ongoing prescribing examined in our shared care and private provider guidance. GPs are asked to hold clinical risk for treatments initiated in a sector whose governance they cannot verify. And as the gatekeeper of the universal system, general practice will be where a two-tier pattern of access first becomes visible to patients: two people in the same waiting room, with the same condition, on very different journeys.
There is also a subtler exposure. If paying becomes normal, general practice itself — underfunded, with the lowest per-patient funding in Scotland here in Lothian — will face its own version of the question, from patients who offer to pay and from clinicians exhausted by unfunded demand. The gates, once opened, may be genuinely difficult to close. That is not a prediction; it is a scenario that deserves to be thought about before it is a decision that has to be taken quickly.
This analysis deliberately reaches no verdict. Reasonable colleagues will weigh the safety-valve and the ratchet differently, and patients making individual choices under pressure deserve sympathy, not judgement, whichever reading one prefers. What seems harder to dispute is that a significant change in the relationship between the public and paid-for healthcare is underway, that it is proceeding largely without deliberate collective decision, and that the professions inside the system should be examining it with open eyes rather than noticing it afterwards.