Simultaneous Use of Public and Private Specialist Services as a Potential Strategic Behaviour in Access to the National Health Service: Is There a Pattern by Socio-economic Level?

Under national health services (NHS), non-urgent access to specialist doctors is not straightforward and sometimes leads to long waiting times. Consequently, some citizens may decide to pay for private specialist care to complement the services provided publicly, trying to shorten their NHS waiting times. This strategic behaviour may lead to inequities in access to public specialist services. A way to approach this phenomenon is to analyse those patients that use private and public specialist care simultaneously. The aim of this paper is to determine the proportion of patients who combine both types of services, their profile and to analyse whether the recent economic crisis has accentuated this phenomenon or not. With survey data from the Spanish Health Barometer between 2005 and 2015, probit models of the probability of combining public and private specialist visits are estimated, controlling for socio-economic, demographic and other individual characteristics. Models are estimated using the Heckman correction technique to solve the potential selection bias problem. Almost one in ten patients who visited a public specialist in the previous year also visited a private specialist. Insofar as these patients have used private specialist care strategically, as complementary services to those of the Spanish NHS, this phenomenon might contribute to generate horizontal inequity in access favouring such individuals, whose profiles respond to a high socio-economic level, young and resident in the regions of Canarias, C. Valenciana, Cataluna, Navarra or Cantabria. With the economic crisis and public budget cuts, the proportion of patients who combine private and public specialist care has declined probably due to the predominance of a "household income effect".