What the Self-Pay Plateau Means for Your Private Practice

By Nita Kotecha, Senior Manager, Healthcare

For two or three years after the pandemic, the story of private practice told itself. NHS elective waiting lists climbed past seven million, patients who had been quietly hoping the queue would move reached the point where they could no longer wait, and self-pay volumes ran ahead of every previous record. Consultants who had thought of private work as something happening at the edges of an NHS career began to find it becoming something closer to a parallel one. Then, somewhere in the middle of 2025, the line stopped going up.

The most recent figures from the Private Healthcare Information Network show that self-pay admissions across the UK were essentially flat in the third quarter of 2025 compared with the same quarter in 2024, while insured admissions hit another record. The full year tells the same story: self-pay growth has stalled, and private medical insurance is doing the work of keeping the market expanding. The funding split has settled at roughly 70% insurance to 30% self-pay, and the direction of travel has been consistent for several quarters now.

This is not a crisis. The private sector treated more patients in 2025 than in any year on record, and the number of consultants working in it reached an all-time high of just under 13,400, up almost 3% on 2024. But the composition of the market has shifted, and that has practical consequences for anyone running a private practice as a business. The question is no longer whether private work is growing. It is what kind of private work is growing, and what that means for how a practice is built and structured around it.

Why has self-pay stopped growing?

For a long time, the self-pay boom looked open-ended. NHS waiting lists were not going to clear quickly. The political appetite to fix the backlog was real, but the gap between the ambition and the trajectory was visible to anyone reading the monthly figures. Even so, there was always going to be a ceiling. The cohort of patients who can write a cheque for a hip replacement, a knee, a hernia repair or a cataract from savings, home equity or family support is a finite one, and after three intense years that pool has been largely worked through.

Layer onto that a sustained period of elevated mortgage rates, household budgets stretched by energy and food, and a softening labour market in parts of the country, and the marginal self-pay patient becomes harder to find. The people who were always going to pay still are, but the people who could just about have paid in 2023 are now waiting it out or making do. Insurance, meanwhile, has continued to grow, partly because more employers are putting PMI back into their benefits packages in response to NHS pressure, and partly because individual policyholders renewing in 2025 and 2026 are finding the value calculation easier than they did three years ago.

What does an insurance-led market actually mean?

A self-pay episode and an insured episode are not the same business transaction wearing different clothes. When a patient is paying directly, the consultant sets the fee. When the insurer is paying, the fee is governed by that insurer’s schedule, and the consultant either accepts it, accepts it with a shortfall to be billed to the patient, or sits outside the insurer’s recognised network altogether. Each of those routes has trade-offs, but none of them puts the consultant in the position the self-pay surge briefly did, where demand was sufficiently strong that a practice could write its own price list and find patients willing to pay it.

The insurers’ fee schedules have not kept pace with practice costs in the way many consultants had hoped, and the regional variation in those schedules continues to be a sore point, particularly outside London. A general surgeon working out of a private hospital in the Midlands is operating on a different fee assumption to a colleague doing the same procedure on Harley Street, and the insurer’s view of that often does not reflect the difference in overheads or in market expectations. When I sit down with a consultant who is restructuring their private work, this is usually the first issue they want to talk through.

Has the supply side moved too?

Yes, and noticeably. Trauma and orthopaedics remains the specialty with the largest number of active private consultants, but the headline figure from the latest PHIN data is the surge in general surgery, where 382 additional consultants became active in 2025, a 16.8% rise on the previous year. Other specialties have grown more modestly, but the overall direction is one of more consultants entering at exactly the point at which the most profitable end of the market, self-pay, has flattened. That is a textbook supply and demand mismatch, and it places downward pressure precisely where consultants have least negotiating power, which is on insurer-funded work.

What does this mean for the way a practice is structured?

A private practice that was set up between 2022 and 2024 was often built on assumptions that do not quite hold now. The income mix assumed continued growth in self-pay. The capacity assumptions, including the number of clinics, the support staff, the room hire and the marketing spend, were calibrated to a market that was still expanding at its top end. The corporate structure, in many cases a limited company set up to ring-fence private earnings and provide flexibility on profit extraction, made sense against a forecast that has now changed.

None of that means the structure was wrong. But it is worth revisiting. A practice that is now drawing more of its income through insurer-paid routes has a different risk profile, a different cash flow rhythm, and often a different cost base than one that was forecasting another twenty per cent in self-pay growth this year. The questions worth asking are practical ones. Is the practice’s marketing spend still pointed at the patients it is actually winning? Is the support infrastructure still proportionate to where the revenue is coming from? Does the company’s profit extraction strategy still make sense once the variable element of self-pay has flattened out? Where is the practice most exposed if an insurer revises its fee schedule downwards, or removes a specialty from a network?

These are not crisis questions. They are the ordinary questions of a business that has reached the end of one phase and the beginning of another. The consultants I work with who are taking the time to ask them now tend to be the ones who do not have to ask them in a hurry later.

Where does this leave the next eighteen months?

The private sector is not contracting. Total admissions in 2025 were higher than in any year before, and the underlying demand for elective work is not going anywhere while the NHS recovery plan remains a multi-year exercise. But the easy growth, the kind that masked structural questions about how individual practices were set up, is no longer there to lean on. The next phase will reward consultants who treat their private practice as a business rather than as an overflow channel, and who are willing to look at the numbers on their own terms.

The conditions of the last three years were unusual, and the conditions of the next three will look closer to the long-run average than to the boom. That is not a bad place to be. It is just a different one to plan for.

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This article has been prepared for information purposes only. Formal professional advice is strongly recommended before making decisions on the topics discussed in this release. No responsibility for any loss to any person acting, or not acting, as a result of this release can be accepted by us, or any person affiliated with us.

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