This blog will explore the extent of private healthcare use in Scotland. Since the National Health Service (NHS) was established in 1948, there has always been a range of health services available privately, and the ability to undertake some private work has always been part of the consultant contract.
What is private healthcare?
Private healthcare is generally not provided on the NHS and is often paid for by an individual or an insurance scheme. It can take place in an independent hospital or clinic.
The National Health Service (Scotland) Act 1978 defines independent health care services as:
- an independent hospital
- a private psychiatric hospital
- an independent clinic
- an independent medical agency
- an independent ambulance service
There are a number of exemptions set out in the Act, such as clinics in a school and those provided by an employer only which only provide services to its employees.
How many private hospital admissions are there in Scotland?
In 2023, there were 46,000 private hospital admissions in Scotland. This is an 11% increase from 2022 and represents the highest number of admissions than in any other year (this is based on private activity only and does not include NHS funded activity).
To put it into the wider context, there were around 1.1 million admissions into NHS Scotland hospitals in 2022/23 – a 3% increase compared 2021/22 (this figure includes patients who receive treatment paid for by the respective NHS Board at a private (independent) hospital).
How is private healthcare paid for?
Private healthcare is generally paid for through insurance schemes or self-funded by an individual. In 2023, 54% of admissions in Scotland were reported to be paid though insurance schemes with 46% being self-paid admissions.
The cost of treatment varies by the provider used and individuals’ treatment plans.
What sort of treatments and procedures take place in private hospitals?
There is a wide range of services available from private healthcare providers in Scotland. In relation to independent hospital admissions the most common procedures in 2023 were cataract surgery, hip replacement, diagnostic upper gastro-intestinal endoscopies, chemotherapy, and diagnostic colonoscopies.
At the end of March 2024, the median waiting time for inpatient or day case admission in NHS Scotland was 110 days for ophthalmology, 206 days for orthopaedics and 176 days for clinical oncology., At the end of March 2024, 23,285 people had been waiting between 92 and 182 days for upper endoscopies and 23,285 people had been the same time for diagnostic colonoscopies, with over 3,000 waiting more a year. However, it is worth noting that NHS waiting times are not the only reason that people choose private healthcare.
Other services are available from the independent sector including a range of diagnostic procedures, surgical procedures, primary care services and mental health diagnosis and support.
Does the NHS use private healthcare providers?
Every year a number of procedures are carried out for the NHS in private (independent) hospitals and other non- NHS settings (such as care homes and hospices), these are paid for by the patient’s NHS Board.
In January 2021, after the COVID-19 pandemic, the Scottish Government announced that private sector hospitals would be used to support planned urgent care and cancer treatment, including breast surgery, urology, and gynaecology. This was set out in the Winter Preparedness Plan 2020/21.
How much does the NHS spend on private healthcare?
Audit Scotland has provided information from NHS health board accounts on expenditure in relation to goods and services from private providers. The total private spend by health boards (including NHS Golden Jubilee and Healthcare Improvement Scotland) in 2022/23 was £115,599,000.
The graphic below shows spend on private healthcare by NHS board between 2018/19 and 2022/23.
This section will be updated in September 2024.
Does NHS Scotland pay for private treatment if a patient’s waiting time has exceeded the Scottish Government’s target?
The Patient Rights (Scotland) Act 2011 states Health Boards must take all reasonably practicable steps to ensure they comply with the treatment time guarantee (TTG). If the health board is unable to treat a patient in its own area within the TTG it should consider using another health board or a suitable alternative provider of the treatment. It is up to each health board to decide on a case-by-case basis whether it will use private healthcare facilities.
The Chief Medical Officer (CMO) set out the arrangements for NHS patients receiving healthcare services through private healthcare arrangements in letter SGHD/CMO(2009)3.
Will the NHS pay for aftercare or private prescriptions?
Medication from a private prescription can sometimes be provided by the NHS under shared care arrangements. There is currently no NHS policy regarding adopting shared care arrangements; instead, this decision is at the clinical discretion of the GP, and the decision is sometimes made at practice or local NHS Board level.
In relation to aftercare following private treatment overseas the Scottish Government has stated:
“While the NHS in Scotland will always provide emergency care where necessary, all routine pre and post-operative care should be part of the package of care purchased by the individual patient.
There will be no obligation on NHS Boards to provide such routine pre and post-operative care. In the event of a patient advising a healthcare professional of plans to travel overseas for privately arranged and purchased surgery, they should be advised firstly that this is not recommended, and secondly that there will be no obligation on their local NHS Board to provide routine pre and post-operative care.
All care required should be provided within the package of care sold by the overseas provider.”
The Scottish Government went on to confirm that when people present to health care services with problems resulting from privately arranged and funded surgery overseas it does not expect GPs to be obliged to provide such routine associated management required as scans, blood tests, follow-up treatments or arrangements to deal with complications as required by the private sector but should always provide care based upon their own judgement, and in keeping with the GMC’s guidance on Good Medical Practice, local board policies, procedures and pathways.
What about primary care?
There are a number of private GP practices in Scotland. These GP practices do not hold a contract with the health board and all their services are provided privately. However, the majority of GP practices still hold a contract to provide NHS services.
In contrast, most high street dentists do a mixture of NHS and private work. In Scotland, of the dentists who responded to a General Dental Council survey, 20.9% said they undertook a mix of private and NHS work, 10.5% said they did predominately private work (at least 75% of time spent on private care) and 5.4% said they only did private work.
Similarly, high street opticians, provide a mix of private and NHS work, with optometrists being able to claim for eye examinations and in some cases for optical vouchers for glasses.
Other primary care services which do a mix of private and NHS work include pharmacists and audiology services.
How is private healthcare regulated?
Healthcare Improvement Scotland (HIS) regulates independent healthcare services in Scotland. It is responsible for regulating independent hospitals, independent clinics and independent medical agencies.
Recently, the definition of an independent clinic has been widened to include clinics where services are provided by pharmacists and pharmacy technicians. The definition of an independent medical agency has also been changed to include services that are provided by dental practitioners, registered nurses, registered midwives, dental care professionals, pharmacists and pharmacy technicians. The updated definition will also regulate wholly online services that are based in Scotland.
HIS undertakes inspections of independent healthcare services to ensure they comply with relevant standards and regulations and reports. It is worth noting that HIS only regulates independent clinics where regulated health professionals work.
Many healthcare professionals are regulated by healthcare regulatory bodies such as the General Medical Council and the General Dental Council.
What about non-surgical cosmetic procedures?
The Scottish Government has recently reconvened the Scottish Cosmetic Interventions Expert Group (SCIEG) to gather insight into the current non-surgical cosmetics landscape. The group has been considering several areas, including classification of procedures based on associated risks and complication management, age restrictions, and the levels of training/qualifications/supervision required to perform these procedures safely.
The Scottish Government has indicated that it intends to consider bringing forward regulation of non-surgical cosmetic procedures in the future.
What about private ambulances?
There have also been calls for regulation of private ambulances. Petition PE 2078 called for the introduction of mandatory licencing and inspection of private ambulance service providers. This petition is currently under consideration by the Citizen Participation and Public Petitions Committee.
The Public Services Reform (Scotland) Act 2010 includes independent ambulance services in the definition of independent health care services. However, HIS has confirmed that at present independent ambulance services are covered in legislation as a type of independent healthcare service but, as the legislation has not been commenced, HIS is unable to undertake any regulatory activity.
In his submission to the Public Petitions Committee, the Cabinet Secretary for Health and Social Care said:
“The commencement of HIS’ functions in relation to the regulation of independent ambulance services is therefore being considered as part of the next phase in the regulation of independent healthcare […] Once the scope of further regulation has been developed, a public consultation will be required. Unfortunately, it is not possible at this point to confirm a timeline of when provisions would be in place”.
Where can I find out more?
The Private Healthcare Information Network has information on private healthcare providers and also publishes a quarterly market update for Scotland and the rest of the UK.
Many think tanks and professional organisations have also commented on the use of private healthcare such as:
You may also find the SPICe blog on waiting times and the forthcoming SPICe blog on ADHD shared care agreements interesting.
Lizzy Burgess, Health and Social Care Team, SPICe Research