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J Public Health (Oxf). 2017 Sep 1;39(3):593-600. doi: 10.1093/pubmed/fdw060.

Patient choice and private provision decreased public provision and increased inequalities in Scotland: a case study of elective hip arthroplasty.

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Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London E1 2AB, UK.



This is the first research to examine how the policy of patient choice and commercial contracting where NHS funds are given to private providers to tackle waiting times, impacted on direct NHS provision and treatment inequalities.


An ecological study of NHS funded elective primary hip arthroplasties in Scotland using routinely collected inpatient data 1 April 1993-31 March 2013.


An increased use of private sector provision by NHS Boards was associated with a significant decrease in direct NHS provision in 2008/09 (P < 0.01) and with widening inequalities by age and socio-economic deprivation. National treatment rate fell from 143.8 (140.3, 147.3) per 100 000 in 2006/07 to 137.8 (134.4, 141.2) per 100 000 in 2007/08. By 2012/13, territorial NHS Boards had not recovered 2006/07 levels of provision; this was most marked for NHS Boards with the greatest use of private sector, namely Fife, Grampian and Lothian. Patients aged 85 years and over or living in the more deprived areas of Scotland appear to have been disadvantaged since the onset of patient choice in 2002.


NHS funding of private sector provision for elective hip arthroplasty was associated with a decrease in public provision and may have contributed to an increase in age and socio-economic inequalities in treatment rates.


epidemiology; health services; social determinants

[Indexed for MEDLINE]

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