Patient choice and the use of the private sector for hip surgery was found to be associated with a decrease in National Health Service provision iand may have contributed to an increase in age-related and socio-economic treatment inequalities, according to research by Queen Mary University of London.
The study is the first to look at the impact of diverting NHS funds to the private sector on NHS provision. By comparing rates of hip surgery carried out by NHS and private providers, the study suggests that the more contracting undertaken by NHS Boards in Scotland with the private sector, the greater the reduction in NHS provision. Patients aged 85 years and over or living in the more deprived areas of Scotland may have also been disadvantaged since the introduction of the Patient Choice policy in 2002, through lower increases in treatment rates compared to other groups.
Lead author Graham Kirkwood from QMUL’s Blizard Institute said: “The claim made by NHS Scotland’s 2003 white paper that the additional use of the private sector would provide ‘sustainable local solutions to long waits’ for elective hip replacement is not supported by the evidence. The involvement of the private sector was supposed to provide extra capacity to tackle long waiting times, so in theory, we should see NHS treatments stay at the same level or increase. Instead our results show the level of NHS treatments going down during a period of high private sector activity.”
Between 2006/07 and 2008/09, an increase in the number of treatments commissioned from the private sector by NHS Boards was found to be significantly associated with a decrease in the number of treatments commissioned from the NHS. This period represents the peak of private sector activity, and the study authors say the association may have been due to the signing of the first block contract (worth £18.7m) between the NHS and the private healthcare sector in Scotland in November 2006.
Those NHS Boards with the greatest use of the private sector for elective surgery experienced the largest reductions in direct NHS provision and of those Fife, Grampian and Lothian NHS Boards had not recovered 2006/07 levels of in-area provision by 2012/13.
The study looked at changes in treatment inequality following the introduction of the Patient Choice policy in 2002, a policy whereby patients can choose to obtain their treatment from an out of area NHS provider or a private provider, funded by the NHS. From 2002/03 to 2012/13, patients aged 75–79 years increased their treatment rate by 65.7%, while those aged 85 years and over increased their treatment rate by 31.3%.
The researchers also looked at the Scottish Index of Multiple Deprivation (SIMD), where different SIMD quintiles represent 20% of the Scottish population living at a certain level of socio-economic deprivation. From 2002/03 to 2012/13, the two least deprived quintiles SIMD 4 and 5 increased their treatment rates by 67.3% and 85.4% respectively while the two most deprived quintiles SIMD 1 and 2 increased their treatment rates by 47.7% and 49.5% respectively.
Co-author Professor Allyson Pollock from QMUL’s Blizard Institute said: “The 2010 UK wide Equality Act legislated for public bodies such as the NHS to tackle inequalities in the delivery of care by a range of factors including age, sex and socio-economic deprivation. Our results are therefore concerning and complement other studies that have shown that the private sector is risk averse and more likely to select out healthier and less poor patients.
“It is current Scottish government policy to eliminate the use of the private sector for elective surgical NHS care, although concerns are being raised over increasing use of the private sector in the past few years. In contrast, England is now dismantling its NHS and accelerating privatisation.”
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.
G Kirkwood, AM Pollock