Background In February 2003, ‘Partnership for Care – Scotland’s Health White Paper’ invoked spare capacity in the private sector as a means of treating NHS patients whose waiting times exceeded the national guaranteed limits. No evidence was given in support of the policy of giving patients a choice of provider with the intention that this would ‘complement and not detract from NHS Boards’ corporate responsibility to develop sustainable local solutions to long waits’.

Previous research using data on elective hip replacements has found evidence that the use of the private sector to provide NHS funded treatment disadvantaged older patients and patients from the most socio-economically deprived areas of Scotland.

Methods Data on NHS funded elective operations performed by the NHS and by private providers were extracted from Information Services Division NHS Scotland admitted patient care datasets for: hip replacements; knee replacements; cataract operations; arthroscopies; cholecystectomies; and inguinal hernia operations.

Using a segmented regression model built around the introduction of patient choice, changes in inequality between patients living in the most socioeconomically deprived and least socioeconomically deprived areas of Scotland were analysed. Similarly models were built to test for changes in inequality between the oldest patients and the other age groups.

Results Initial findings show that after the introduction of patient choice, there is evidence that patients living in the most socio-economically deprived areas had levels of inequality increase for cataract operations, 1.62% increase (95% confidence interval 1.58%, 1.66%) and cholecystectomies, 0.42% increase (0.36%, 0.48%) although inequality may have decreased by 0.66% (0.64%, 0.68%) for arthroscopies.

For the oldest patients (85 years and over for hip, knee and cataract; 70 years plus for arthroscopy; and 80 years plus for cholecystectomies; and inguinal hernia operations) there is evidence of improving inequality for hip replacements with a 1.42% reduction in inequality (1.53%, 1.31%) whereas inequality appears to have increased by 0.11% (0.09%, 0.13%) for cataract patients and by 4.00% (3.96%, 4.03%) for arthroscopy patients.

Conclusion Patient choice was introduced in Scotland and England with no evidence to support it and with very little evaluation since. This research shows that that for some of the most vulnerable patients and for certain procedures there may be a widening of inequalities which may be a result of the operation of patient choice. Conversely reductions in inequality may have occurred in some cases. Further research is necessary to understand the mechanisms involved in any such changes in inequality.