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Preferences and trade-offs for the private-public mix in National Healthcare Systems (NHS)

A discrete choice experiment across four OECD countries

LSE Principal Investigator: Marcello Antonini and Chiara Berardi
Start Date: 1 April 2025
End Date: 1 April 2026
Funder: LSE Pilot Research, Dissemination & Impact Fund
Regions: Europe
Countries: England, Italy, Denmark, Sweden
Partners: DemetraOpinioni
Keywords: Health inequalities

National health systems worldwide face mounting pressures from aging populations, rising costs, and workforce shortages. A common policy response has been increased private sector involvement in healthcare financing and provision, yet there is limited understanding of public preferences regarding these reforms. Recent Lancet and BMJ Commissions emphasise the need for values-based approaches to NHS reform, yet most existing research relies on traditional satisfaction surveys that cannot capture trade-offs or willingness to pay for different system configurations.

This project aims to:

  • Develop comparative case studies of NHS systems with varying public-private arrangements across four countries
  • Explore population preferences regarding the balance of public and private involvement in healthcare financing and provision
  • Generate evidence-based, patient-centred policy recommendations to guide NHS reforms

The research uses a discrete choice experiment (DCE) methodology, which allows participants to make trade-offs between healthcare system features such as waiting times, out-of-pocket costs, provider choice, and the extent of private sector involvement. The project unfolds in two phases. First, a comparative case study examines the public-private mix in financing and provision across England, Italy, Denmark, and Sweden—countries chosen for their shared NHS foundations but diverse privatisation approaches. This phase includes literature reviews, quantitative data from international organisations, and key informant interviews with policymakers and experts to identify the attributes that will define the DCE. Second, a cross-sectional survey including the DCE will be conducted with approximately 4,000 adults across the four countries, administered through a specialised market research partner to ensure representative samples. Statistical models will analyse how preferences vary by demographic and socioeconomic factors, and estimate willingness to pay for changes in system configuration.

The project will produce a novel multi-country dataset on public preferences, with at least two journal articles in leading health policy outlets, and policy briefs for the LSE Department of Health Policy websites. Initial findings will be presented at the European Health Policy Group meeting (Spring 2025) and other international conferences (such as EuHEA). Results will be disseminated through patient organisations like the National Association for Patient Participation and professional bodies like the British Medical Association to ensure public and workforce voices inform policy debates.

This research directly addresses challenges highlighted in major NHS reform commissions by incorporating public preferences into policy recommendations. It provides policymakers with evidence to optimise the public-private balance in ways that align with societal values while promoting both equity and efficiency.