Is 'two-tier' healthcare now inevitable?

Earlier this month, Spire Healthcare - which has two hospitals in Edinburgh - reported "unprecedented demand" from patients paying for their own treatment.

Revenue from "self-pay" - which is distinct from patients covered by health insurance - increased by 115% across the group's UK sites in 2021, and now makes up 26 per cent of its total revenue compared to 18% pre-pandemic.

Justin Ash, Spire Healthcare's chief executive, said Covid had ushered in a "fundamental shift" as "record waiting lists have led more people to prioritise their health and choose to use independent providers".

Scotland still has comparatively few private hospitals compared to the rest of the UK (eight in total, compared to 19 in London alone) but they are treating more patients than ever before.

READ MORE: Spire Healthcare reports 'unprecedented demand' from patients paying for their own treatment

Data from the Private Healthcare Information Network (PHIN) - an umbrella body for the indepedent sector - shows that 35,440 patients underwent procedures in Scotland's private hospitals in the 12 months to September 30 2021, up by 7% compared to the year to March 2020.

This includes both self-pay and insurance-funded patients, as well as NHS patients sent to private hospitals.

Unsurprisingly, the procedures facing the longest delays on the NHS were also the most popular in the private sector, which carried out 6,900 cataract surgeries, 1,800 diagnostic colonoscopies, 2,105 hip replacements, and 1,080 knee replacements.

It is also notable that while activity has increased in the private sector, it has never even returned to pre-pandemic levels in the NHS.

The number of people being admitted to NHS hospitals each week in Scotland remains well below the pre-pandemic average

In the week ending February 20, total admissions - emergency and elective combined - were 15% below the average for 2018/19, reflecting how ongoing physical distancing restrictions in healthcare have reduced capacity as well as spiralling numbers of Covid positive patients who have to be isolated.

In a hospital without single-bed rooms, this means 'cohorting'.

For example, in an orthopaedics department which has three 10-bed wards and two Covid positive patients, one of the wards would be set aside for these two patients alone - making eight beds suddenly unavailable for patients due to be admitted for hip and knee surgeries.

Similar protocols are used to isolate patients with flu or norovirus, but the sheer prevalence of Covid now - with one in 14 Scots infected - makes this virus unusually problematic for the NHS.

READ MORE: One in 20 patients waiting over two years for operation on NHS Scotland

Given that Covid isn't going to disappear, then, how do we tackle the ever-increasing elective backlog?

The Scottish Government's plan is to increase capacity through the creation of eight new elective hubs, plus an expanded Golden Jubilee, capable of delivering "at least 40,000 additional elective surgeries and procedures per year" by 2026 - equivalent to a 10% uptick on pre-pandemic activity.

The first of the National Treatment Centre elective hubs, in Forth Valley, Fife, and Inverness, are due to launch this year

Key to this will be workforce.

In its National Workforce Strategy for Health and Social Care, published on March 11, the Scottish Government pledged to "grow our NHS workforce over the next five years by 1%".

The discrepancy was not lost on Dr Bernie Scott, deputy chair of BMA Scotland, who noted that a 1% growth in staffing "is difficult to tally with the hoped for growth in capacity".

Dr Scott added that any attempts to drive up staffing should also "guard against the possibility of losing many doctors before new recruitment has any chance of making an impact".

Chief among the bugbears of many a senior consultant is the ongoing saga of punitive pension taper taxes, which have already driven many into early retirement and are likely to deter many more from taking on the extra waiting list work needed if we are ever to meet these ambitious elective activity targets.

The issue is complex and long-standing, but in essence senior doctors who take on extra sessions can find themselves landed with annual tax bills running into tens of thousands of pounds.

READ MORE: NHS pension plan could create more problems than it solves

Ultimately the buck stops with the Treasury, though BMA Scotland insists that Holyrood could do more to mitigate the problem.

This is more urgent than ever since private work- where consultants are employed as freelancers, or via their own limited companies - does not attract these charges.

Instead, medics are paid a gross with no pension or national insurance deductions.

As Dr Phil Hammond, a retired medic and Private Eye's 'MD' health writer, noted this week: "If consultants in the NHS could get the same - maybe there would be more take up of extra sessions. If not, private work will continue to grow at the expense of NHS work."

Training and recruiting NHS staff is only part of the battle: keeping them in the NHS is another matter.

CASE STUDY: 'I had the choice of becoming an old man, or going private'

In London, a new £1 billion, 184-bed private hospital run by US provider, Cleveland Clinic, is set to open at the end of this month where patients will have views of Buckingham Palace and consultants are reportedly set to earn fixed salaries of £350,000 a year.

David Rowland, director of the thinktank Centre for Health and the Public Interest, noted that the two-tier problem goes beyond a split between patients who can and cannot pay; the private sector simply pulls nurses and consultants away from the NHS by "paying significantly more".

Particularly in ophthalmology, growing numbers of consultants are leaving NHS jobs to join large private firms - a bad sign for anyone awaiting cataract surgery.

If money talks, what is all this telling us about the long-term prospects for the NHS?

As Rowland put it: “An estimated £1bn investment in a single hospital is a sign of how strongly foreign investors are betting against the NHS being able to meet the future health needs of the population."