Multiple paths to privatisation in healthcare? Comparing England and Italy beyond the public–private divide

English and Italian national health systems are predominantly funded by general taxation and treat patients primarily free at the point of delivery. Both healthcare systems are facing increasing financial pressures given population ageing, the rise in chronic and non-communicable diseases, and fiscal restraint. In recent years, pressures on public healthcare have revived debate around the role of the private sector, but discussion is mired in a lack of conceptual clarity. We seek to bring greater analytical order by distinguishing seven distinct ‘trajectories of privatisation’, each reflecting different modes and logics of interaction between public and private actors. We examine two similar health systems – England and Italy – highlight their similarities and differences regarding emerging and established trajectories. There is less evidence of ‘hard privatisation’, seen as the private share of overall spending; however, both countries are experiencing greater use of on-demand staff and financialisation. In both systems subtler privatisation dynamics (public-private partnerships, managerialism, and entrepreneurialism) are redefining and blurring the boundaries between public and private provision. Public perceptions of perceived privatisation are shaped by direct, tangible experiences of care and out-of-pocket spending. Some privatisation dynamics are mainly driven by behaviour of patients, professionals, and investors rather than by policies.