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

Lookup NU author(s): Graham Kirkwood, Professor Allyson PollockORCiD



This is the authors' accepted manuscript of an article that has been published in its final definitive form by Oxford University Press, 2017.

For re-use rights please refer to the publisher's terms and conditions.


Background: 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. Methods: An ecological study of NHS funded elective primary hip arthroplasties in Scotland using routinely collected inpatient data 1 April 1993–31 March 2013. Results: 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. Conclusions: 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.

Publication metadata

Author(s): Kirkwood G, Pollock AM

Publication type: Article

Publication status: Published

Journal: Journal of Public Health

Year: 2017

Volume: 39

Pages: 593-600

Print publication date: 01/09/2017

Online publication date: 28/07/2016

Acceptance date: 23/05/2016

Date deposited: 15/01/2018

ISSN (print): 1741-3842

ISSN (electronic): 1741-3850

Publisher: Oxford University Press


DOI: 10.1093/pubmed/fdw060


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