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

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privately in England and Wales was 13.2%, and in 1986 it was 14.8%.¹ For 1992-3 it was 14.1% (BT Williams, JP Nicholl, unpublished data).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.

Comment

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).⁴However, 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.

Table.

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

Operation or procedure	Independent hospitals				NHS hospitals			% privately funded
	Private	NHS	Total*		Private	NHS	Total
Eyes and ear, nose, and throat
Lens operations	29 159	3 921	33 218		4 817	168 282	173 099	16.5
Other eye operations	8 572	270	8 899		2 652	138 295	140 947	7.5
Tonsillectomy and adenoidectomy	11 223	1 730	13 036		604	86 098	86 702	11.9
Drainage of middle ear	10 413	425	10 872		390	52 649	53 039	16.9
Other ear, nose, and throat	23 540	1 964	25 700		2 500	186 857	189 357	12.1
Dental operations	20 184	733	21 186		753	153 380	154 133	11.9
Heart or blood vessels
Operations on coronary arteries	4 369	445	4 843		1 113	21 205	22 318	20.2
All other heart operations	10 540	583	11 162		2 805	80 673	83 478	14.1
Ligation or stripping of varicose veins	12 782	1 888	15 058		505	48 340	48 845	20.8
Gastrointestinal tract
Cholecystectomy	6 022	336	6 390		441	30 316	30 757	17.4
Other major intra-abdominal operations	6 651	33	6 684		1 359	53 389	54 748	13.0
Diagnostic or therapeutic endoscopy of gastrointestinal tract	62 655	3 079	65 995		6 693	524 993	531 686	11.6
Abdominal hernia repair	20 424	1 398	21 973		1 104	80 633	81 737	20.8
Haemorrhoidectomy and other anal or perianal operations	8 946	634	9 648		654	52 414	53 068	15.3
Operations for men
Prostatectomy	6 080	430	6 544		571	39 524	40 095	14.3
Vasectomy	2 384	1 874	4 310		190	36 913	37 103	6.2
Circumcision	3 250	90	3 374		281	24 372	24 653	12.6
Gynaecological
Dilatation and curettage	3 838	100	3 938		332	44 213	44 545	8.6
All hysterectomy	10 320	562	11 018		631	59 223	59 854	15.5
Repair prolapse of vagina or uterus	5 198	107	5 305		262	22 219	22 481	19.7
Other gynaecological	42 052	917	43 177		2 443	197 356	199 799	18.3
Division, ligation, occlusion of oviducts	469	449	918		195	47 432	47 627	1.4
Breast
Total excision of breast	2 051	96	2 147		126	13 164	13 290	14.1
Partial excision of breast	7 116	456	7 572		466	34 983	35 449	17.6
Orthopaedic
Total replacement of hip joint	9 571	1 655	11 299		1 136	35 239	36 375	22.5
Total replacement of knee joint	5 041	924	5 965		419	25 960	26 379	16.9
Other orthopaedic operations	36 362	2 146	38 833		3 330	197 058	200 388	16.6
Diagnostic or therapeutic endoscopy of joint	32 026	2 774	35 287		1 229	78 827	80 056	28.8
Miscellaneous
Cosmetic operations	23 165	219	23 663		683	37 414	38 097	38.6
Gender reassignment	104	0	104		6	46	52	70.5
Removal of lesion of skin	19 406	1 349	21 122		1 139	169 764	170 903	10.7
All other operations or procedures	93 003	5 624	99 429		13 285	1 003 960	1 017 245	9.5
Type of operation not known	1 001	93	1 094		724	36 543	37 267	4.5
Total operations or procedures	537 917	37 304	579 762		53 838	3 781 734	3 835 572	13.4
No operation or procedure (includes patients treated medically)	131 381	4 638	136 350		16 674	526 046	542 720	21.8
Total (surgical and medical)	669 298	41 942	716 112		70 512	4 307 780	4 378 292	14.5

^*Includes cases in which method of funding is not known.