title: Patient choice and private provision decreased public provision and increased inequalities in Scotland: a case study of elective hip arthroplasty.
abstract: 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.
authors.affiliation: Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London E1 2AB, UK.
authors.forename: G
authors.initials: G
authors.lastname: Kirkwood
authors.affiliation: Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London E1 2AB, UK.
authors.forename: A M
authors.initials: AM
authors.lastname: Pollock
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000523:psychology / Q000706:statistics & numerical data*; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D057240:Patient Preference / Q000706:statistics & numerical data*; D017149:Private Sector / Q000706:statistics & numerical data; D011332:Privatization / Q000458:organization & administration / Q000706:statistics & numerical data; D017150:Public Sector / Q000706:statistics & numerical data; D012606:Scotland; D013222:State Medicine / Q000458:organization & administration / Q000706:statistics & numerical data; D014850:Waiting Lists
keywords: epidemiology; health services; social determinants