Why UK private healthcare has always been secondary, not primary

Every UK city has private hospitals. Harley Street has been a byword for private specialist medicine for more than a century. Major insurers and a long list of hospital groups provide private cover for elective surgery, diagnostics, and consultant clinics. This has been true, in broadly its present shape, since the National Health Service (NHS) was founded in 1948.

Private general practice is different. Until very recently the private primary-care market in the UK was vanishingly small, limited to a handful of Harley Street practices, a few embassy and occupational clinics, and a short list of specialist travel clinics. The last ten to fifteen years have seen that change. Private general practitioners (GPs), walk-in clinics, and online GP services have scaled into a market worth around £1.6 billion in 2024, but this is still a small fraction of the scale of private secondary care.

This article sets out why the UK private sector developed so differently in primary and secondary care, why that asymmetry persisted, how it is beginning to shift, and what a properly established private primary-care layer might do for the patient and for the wider system. Sources are at the end.

The 1948 settlement included a private channel for hospital medicine

When the NHS was created in 1948, the existing private healthcare economy did not disappear. It was folded in, partially, through a set of negotiated compromises. The history of the NHS settlement is clear on this: "agreements had to be thrashed out with GPs, doctors and consultants to allow private practice to continue and sit alongside the new national health service."

For hospital medicine, three mechanisms preserved a private channel from day one.

• Consultant contracts allowed private practice. Full-time NHS consultants had their hours capped; part-time consultants kept a private list. Historically, part-time consultants derived roughly a third of their income from private practice.

• NHS hospitals contained pay beds and amenity beds. Private patients could be treated within NHS hospital facilities, often by the same consultants who saw them under the NHS. The Health Services Act 1976 progressively reduced pay beds in NHS hospitals, but the broader private-within-public channel continued.

• Independent private hospitals existed and grew. Pre-NHS voluntary hospitals, mission hospitals, and private clinics persisted. New independent hospital groups emerged from the 1960s onwards, scaled through the 1980s and 1990s, and now make up the backbone of the UK's private hospital sector.

Alongside the provider side, an insurance market developed. The British United Provident Association (BUPA) was founded in 1947, the year before the NHS, and a range of other insurers followed. About eight per cent of the UK population now holds some form of private medical cover, most of it through employer schemes.

How private secondary care developed over seventy-seven years

The private secondary-care sector in the UK today is substantial. The LaingBuisson UK private healthcare market review valued the overall UK private healthcare market at around £12.4 billion. The bulk of this spend is in secondary care: elective surgery, diagnostic imaging, cancer treatment, cardiology, orthopaedics, gastroenterology, and the full range of consultant specialties.

The channels through which it is delivered have remained broadly stable for decades.

• Independent hospital groups. National and regional chains of private hospitals across the UK.

• Private care within NHS facilities. Private patient units (PPUs) operate inside many NHS trusts, particularly in London teaching hospitals, and provide substantial income back into the NHS.

• Specialist consulting rooms. Harley Street and its equivalents in other cities host consultants in private practice alongside NHS commitments.

• Diagnostic and imaging centres. Private-only or mixed-use scanning and diagnostics businesses.

• NHS-commissioned private activity. The NHS itself purchases hospital activity from the independent sector where capacity or waiting times require it, through national frameworks.

What every one of those channels has in common is that the staffing model relies on the same consultants who also work in the NHS. A private hospital in the UK is typically a facility that rents operating theatres and beds to consultants whose main employment is in an NHS trust. The two systems share their workforce.

Why private primary care did not develop in parallel

Private general practice never scaled to anything like the same size. For seventy years it was a small boutique market. Three structural reasons explain the gap.

First, NHS general practice was already a private-partnership model. From 1948, GPs were independent contractors holding an NHS contract, not employees. The natural route for a patient who wanted a private GP was simply to register with the NHS practice they would have used anyway, because that practice was already an independently run small business with continuity of care, a local relationship, and no fee at the point of use. Unlike hospitals, where the NHS and private sector sat as two obviously different providers, in primary care the NHS and the local GP partnership were the same organisation.

Second, NHS primary care historically worked well on the patient-access measures that private practice normally competes on. For most of the NHS's history, registering with a GP gave a patient easy access to a regular doctor who knew them, was around the corner, and had time to know their family. There was no large group of patients frustrated by the NHS primary-care experience and willing to pay to leave it.

Third, the economics of private general practice are harder than the economics of private consultant practice. A consultant doing private work sells high-ticket procedures, scans, operations, and single-episode expertise, funded mostly through insurance. A private GP sells fifteen or twenty-minute consultations with no equivalent high-ticket back-end. A private general-practice business has to build list-level relationships, a long-run recurring-revenue base, and the infrastructure to support it. That is a tougher commercial model than a private consultant practice, and one that did not emerge at scale in the UK for most of the NHS era.

The current UK private primary-care market

The last fifteen years have changed the picture. Private primary care in the UK is now a recognisable market. It is still small relative to private secondary care, and still small relative to NHS primary care, but the growth is real.

The LaingBuisson 2024 primary care market landscape report set out the scale.

• Private GP market value: £1.6 billion in 2024.

• Share of UK GP consultations that are private: 13 per cent in 2024, up from 3 per cent in 2009.

• Employer spend on private primary care: £400 million per year direct or through health cover.

• Virtual GP services: combined value over £300 million, though most private GP consultations are still delivered face to face.

• Overall primary-care market (NHS plus private): £29 billion.

Two features of the market matter for understanding where it is going.

One: the private primary-care sector is driven by access. Patients are choosing private GP care because of speed of booking, ease of appointment, choice between virtual and in-person delivery, and convenience. It is not a statement about clinical quality; most consulting GPs in private practice also work in the NHS.

Two: the market is still maturing. The private GP sector is fragmented, with independent single-location practices, small chains, large online services, and employer-contracted providers all competing in different parts of the space. None of it is at the scale of the private hospital sector, which is consolidated among a small number of national chains.

Why private primary care is growing now

Several changes over the last decade have driven patient demand upward.

• NHS primary-care access pressures. Patient-reported satisfaction with NHS general practice has declined substantially since 2019 on appointment availability, booking ease, and continuity. This is widely documented, and it creates a market for an alternative route.

• Consumerisation of service expectations. Patients who book theatre tickets, restaurant tables, and plane seats online in three clicks now expect the same of medical appointments. The NHS GP appointment-booking infrastructure has not kept pace.

• Technology-enabled delivery. Video consultations, integrated booking systems, and asynchronous messaging make it economic to deliver private GP services at scale for the first time.

• Workforce mobility. NHS GPs increasingly hold portfolio careers that combine NHS sessions with private sessions, locum work, and digital-service sessions. The same doctors now work across both channels, exactly as consultants have done in secondary care for decades.

• Employer health benefits. Employers are increasingly paying for primary-care access for employees as part of benefit packages. The £400 million employer spend is the most obvious marker of this shift.

These are all compatible with a sector that is still early in its development.

The case for a properly developed private primary-care layer

The UK's experience with a parallel private secondary-care sector is informative. For seventy-seven years the private hospital sector has sat alongside the NHS, staffed by the same doctors, used by a minority of the population as an alternative channel for defined needs. It has not replaced the NHS. It has not undermined the NHS. Where it has interacted with the NHS, in private patient units inside NHS hospitals and in NHS-commissioned independent-sector activity, it has in some cases supplemented NHS capacity. The overall outcome is a country with universal free-at-the-point-of-use healthcare and a parallel private option for those who choose it.

A properly developed private primary-care sector could do something similar for general practice. Patients whose primary need is convenience (appointment time flexibility, video appointments between meetings, longer consultations on demand, same-day access) would have a route that does not depend on the NHS primary-care system accommodating those wants. Patients for whom cost is the constraint, or who need long-term continuity, complex-condition management, prescribing of non-private-priced medication, and the reach of the full NHS apparatus, would stay in the NHS primary-care system that is designed for exactly that work.

This is not an argument for withdrawing resources from NHS general practice. The NHS primary-care system is the core of how healthcare reaches the UK population, and investing in its workforce, premises, and access infrastructure remains essential. It is an argument that the absence of a substantial private primary-care alternative has made the NHS primary-care system the only available option for tens of millions of patients, including many whose primary need is convenience rather than clinical continuity. A private alternative of the kind that already exists in secondary care would give those patients another option, while leaving NHS primary care free to do what it was designed to do.

Important caveats

The argument above rests on three honest points.

• Private primary care makes no claim of clinical superiority. The doctors are in many cases the same individuals. The regulators are the same. The clinical guidelines are the same. What differs is the appointment time, the length of the consultation, the ease of booking, and the channel. Quality of clinical decision-making is a function of the doctor, not the economic model that pays them.

• Private primary care is not a replacement for NHS registration. Continuity of medical record, national screening programmes, long-term condition management, access to NHS prescribing, access to NHS referrals to NHS secondary care: all of these depend on NHS GP registration. Responsible private GP providers, including LoveMyLife, write to the NHS GP after every consultation so the NHS record remains complete.

• Private primary care does not solve complexity. For genuinely complex, urgent, or critical cases, the NHS is the right route. Private primary care is designed around convenience and access, not around high-complexity multi-specialty care. The private hospital sector itself transfers the most complex cases into the NHS, and private primary care sits one level below that boundary.

The honest framing, then, is that private primary care is a channel for patients whose priority is accessibility and convenience, operating alongside an NHS primary-care system that remains the right default for most UK patients most of the time.

The summary

The UK has had a substantial private secondary-care sector since 1948, staffed by the same consultants who work in the NHS, used by a minority of the population, and generally coexisting with the NHS without undermining it. Private primary care, by contrast, was a tiny market for the first six decades of the NHS and has only scaled meaningfully in the last fifteen years.

The reasons are structural. NHS GPs were already independent contractors, NHS primary care historically delivered well on the access measures private practice competes on, and the economics of private general practice were historically harder than the economics of private specialist practice. Those conditions have changed. The private primary-care market is now worth around £1.6 billion, carries roughly 13 per cent of UK GP consultations, and is growing.

A properly developed private primary-care layer is not a threat to the NHS. The private secondary sector has shown for seventy-seven years that a parallel channel can sit alongside universal provision without displacing it. The same pattern in primary care would give patients whose priority is convenience a route of their own, and would leave NHS general practice free to do the work it was designed to do.

Sources and further reading

• NHS England, NHS history. The 1948 settlement and the negotiation with GPs and consultants.

• Wikipedia, Private healthcare in the United Kingdom. Overview of private hospital sector and history of pay beds.

• Wikipedia, History of the National Health Service. The settlement, subsequent acts, and sector evolution.

• legislation.gov.uk, Health Services Act 1976. The statutory basis for the progressive reduction of pay beds in NHS hospitals.

• LaingBuisson, LaingBuisson report shows private pay GP market is booming and valued at £1.6 bn. 2024 private primary-care market data.

• LaingBuisson, Primary Care Market Landscape Report, 1st edition. Segmentation of the UK primary-care market.

• LaingBuisson, Private healthcare market valued at record £12.4bn. Overall UK private healthcare market size.

• GP Patient Survey, gp-patient.co.uk. Patient-reported experience of NHS general practice.

• British Medical Association, Consultant contract and private practice. Consultant contract structure that allows private practice alongside NHS work.

• NHS England, NHS commercial framework for new medicines. NHS-commissioned activity in the independent sector.

About the author

Dr Seth Rankin qualified in medicine at Auckland School of Medicine in New Zealand in 1990 and worked as a junior doctor across New Zealand, Australia, and the UK before qualifying as a Member of the Royal College of General Practitioners (MRCGP) through the London Deanery in 2004. He was Managing Partner of Wandsworth Medical Centre from 2006 to 2016 and served as a Board Member of Wandsworth Clinical Commissioning Group for nine years. He is the founder of London Travel Clinic, London Doctors Clinic, London Medical Laboratory, and LoveMyLife.

Read more about Dr Seth Rankin.

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