When Fabien needed to have a decayed tooth removed in May, his dentist told him that he would have to wait up to three years to have it done on the NHS. In disbelief, the 27-year-old from Edinburgh rang 50 dental practices but without any luck. He had no choice but to go private. Having lost his job during the pandemic, he was on universal credit and had to borrow the £600 from his family. Fabien is one of a growing number of people without health insurance who are paying for medical treatments out of their own pocket. NHS hospital waiting lists in England have reached record levels, hitting 5.6 million this summer, as doctors struggle to clear a growing backlog caused by Covid-19. People on modest incomes, and even those claiming benefits are turning to private providers for knee or hip replacements, cataract removal or even expensive cancer treatment. This week, a survey of 4,000 adults commissioned by charity Engage Britain showed more than a fifth had gone private because they could not get the treatment they needed. While support for the NHS remains high, a quarter said the wait for treatment for themselves or a loved one had had a serious impact on their mental health. Roughly 13% of the UK population has some kind of health insurance, mostly through their employers. The rest are faced with a stark choice – wait months and even years for badly needed treatment, or dig into savings to jump the queue. “The pandemic will have a long-lasting impact on the self-pay market,” says Vernon Baxter, managing director of the magazine HealthInvestor UK. “With the NHS under pressure for the foreseeable future, the concept of paying out of pocket to expedite treatment will be increasingly commonplace – for those who can afford it.” Health data firm LaingBuisson has put the value of the annual self-pay market at £1.1bn, including cosmetic surgery, and says it has grown by 7.1% between 2010 and 2019. That year, private hospital groups derived just over 20% of their revenues from self-paying patients. With private hospitals closed to non-NHS patients during the pandemic, the statistics were not collected last year, but there is every indication they will have jumped dramatically. Last week, Spire Healthcare revealed a 47% surge in half-year revenues from self-paying patients to a record £130m, which lifted its overall revenues nearly 40% from pre-pandemic levels to £558m. The second largest private hospital group in the UK, with 39 hospitals and eight clinics, Spire says the majority of self-paying patients are aged 35 or over, and most have a combined household income of more than £50,000. As Justin Ash, the chief executive, says: “It’s by no means the super well-off.” David Hare, the chief executive of Independent Healthcare Providers Network, the industry body, says many people have built up savings over the past 18 months, having been unable to travel or dine out, and “some want to spend that money to get back full mobility” by having knee or hip surgery. “People are paying for oncology treatment as well,” he says. A similar picture is emerging at Spire’s rivals. The UK arm of US-listed HCA Healthcare, which dominates the London market, has seen a 25% increase in self-pay hip and knee replacements and other orthopaedic procedures, a 20% increase in cardiothoracic ops such as aortic valve replacement and repair, and a 30% rise in neuroscience treatments, such as injections into joints to treat back, head, neck, shoulder, groin or leg pain. People are coming to HCA’s six London hospitals from farther afield than usual, particularly from the south and southwest of England where it has recorded between 25% and 35% more self-paying patients. Britain’s biggest private hospital chain, BMI Healthcare, declined a request to share numbers for its own hospitals. It is part of the Circle BMI group, which now runs 53 hospitals in the UK, and is owned by Centene Corporation, a publicly listed US healthcare giant. Company filings show that at BMI the highest-paid director, thought to be Karen Prins, the chief executive, was paid nearly £1.6m for the year to 31 March 2020. The firm did not pay a dividend but the previous year it paid £1.1bn to its then parent, GHG. Baxter says the private health sector in the UK is “really at a fork in the road”. Operators are deciding whether to position themselves as a partner to the NHS, or as a competitor. David Rowland, director of the thinktank Centre for Health and the Public Interest, says: “There is a big risk that unless government provides adequate funding for the NHS, more and more people will be forced to pay privately, which in turn will undermine middle-class support for a tax-funded NHS. “It’s not likely that we will end up with a US-style insurance system. But a two-tier system, where the NHS is a residual service for those without the means to pay is a possibility – ultimately these are political choices.” Rowland says private operators were already trying to “create a new type of health consumer” who pays for their own treatment before the pandemic, through TV and social media campaigns. They have sought to make self-pay more attractive by offering fixed-price packages and some hospital groups, such as Nuffield Health, are offering zero-interest finance. They have also pushed into lucrative cancer treatments, which became the biggest single earner for private hospitals in London in 2019, as the Cleveland Clinic and other US brands entered the UK. After the pandemic, public support for the NHS remains high. But the government has imposed a hike in national insurance to bring down waiting lists. With many now paying twice for care – first through their taxes and then from their own pockets – that goodwill cannot be taken for granted. “I’m not sure if I’m angry or annoyed,” says Fabien, who is still in debt to his family. “I feel like it’s really unfair that I had to pay for treatment.” The cost of typical operations Knee – more than £9,000 Hip – from £12,060 Cataract – from £2,040 Hernia – £3,077 Slipped disc – £6,525