Waiting times and admissions policies in England and Scotland before and after privatisation of services for elective surgery in England

In 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. To compare trends in admissions, waiting times and inequalities in England and Scotland for hip and knee replacement surgery between April 1997 and March 2019. An 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. Between 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. Scotland increased in-house NHS provision by 18% for both treatments. In contrast in England NHS in-house capacity for hip and knee replacements fell by 8% and 18% respectively between 2008 and 2019, 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. Contracting out NHS funded elective surgery to the private sector in England is associated with the creation of a two-tier system within the NHS.