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Waiting times and admissions policies in England and Scotland before and after privatisation of services for NHS elective hip and knee replacement surgery in England between 2008 and 2019

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

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).

Abstract

© 2026 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC license. http://creativecommons.org/licenses/by-nc/4.0/BackgroundIn the UK, where healthcare is a devolved matter, England and Scotland have different policies to reduce waiting lists for elective surgery. England is redirecting NHS funding to the private sector using commercial contracts, Scotland is expanding in-house capacity.ObjectiveTo compare trends in admissions, waiting times and inequalities in England and Scotland for hip and knee replacement surgery between April 1997 and March 2019.MethodsAn ecological study of NHS funded elective primary hip and knee replacement comparing admission rates, slope index of inequality for admissions and trend gradients for waiting time inequality using interrupted time series.ResultsBetween 1997/98 and 2018/19, the admission rate for hip and knee replacements increased by 110 % to 137.9 per 100,000 and 185 % to 145.4 per 100,000 respectively for England and by 90 % to 144.8 per 100,000 and 163 % to 137.5 per 100,000 respectively for Scotland. Between 2008 and 2019, Scotland increased in-house NHS provision by 18 % for both hip and knee surgeries. In contrast in England NHS in-house capacity for hip and knee replacements fell by 8 % and 18 % respectively, with the private sector substituting for direct NHS provision; NHS funded private providers increased seven-fold to 155. Waiting times fell in both countries and trends were pro-rich in both countries after 2008. Inequality in admissions increased in England at two and a half times the rate of Scotland.ConclusionsContracting out NHS funded elective surgery to the private sector in England is associated with the creation of a two-tier system within the NHS.

Publication metadata

Author(s): Kirkwood G, Pollock AM

Publication type: Article

Publication status: Published

Journal: Health Policy

Year: 2026

Volume: 168

Print publication date: 01/06/2026

Online publication date: 10/03/2026

Acceptance date: 10/03/2026

Date deposited: 13/04/2026

ISSN (print): 0168-8510

ISSN (electronic): 1872-6054

Publisher: Elsevier Ireland Ltd

URL: https://doi.org/10.1016/j.healthpol.2026.105605

DOI: 10.1016/j.healthpol.2026.105605

Data Access Statement: The datasets used for this study were made available to the re searchers under strict licence from NHS Digital England and Public Health Scotland and are not permitted to be made publicly available

PubMed id: 41875794

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