Social Justice Research

, Volume 32, Issue 3, pp 255–276 | Cite as

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?

  • M. A. Negrín
  • J. Pinilla
  • I. AbásoloEmail author


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, Cataluña, 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”.


Public and private specialist visits Waiting times National health service Equity in access Spain 



We are thankful to Jose Cáceres, Pedro Gutiérrez and Aki Tsuchiya for their input. We are also grateful for comments to the participants at the Health Economics and Decision Science seminar (University of Sheffield, August 2018) and at the Applied Economics and Quantitative Methods Department seminar (University of La Laguna, January 2019). We would also like to thank two anonymous referees for Social Justice Research for their valuable suggestions. The usual disclaimers apply.


This study was funded by the Spanish Ministry of Economy and Competitiveness (Project ECO2016-79588-R). It has also had the financial support of the “Project of the Research Programme Maria Rosa Alonso of Social Sciences Ref: 2018-0000209” funded by the Cabildo of Tenerife. We are grateful for such financial support.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Human and Animal Rights

This article does not contain any studies with human participants or animals performed by any of the authors.


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Authors and Affiliations

  1. 1.Departamento de Métodos Cuantitativos en Economía y GestiónUniversidad de Las Palmas de Gran CanariaLas PalmasSpain
  2. 2.Departamento de Economía Aplicada y Métodos Cuantitativos e Instituto Universitario de Desarrollo RegionalUniversidad de La LagunaTenerifeSpain
  3. 3.Facultad de Economía, Empresa y TurismoUniversidad de La LagunaLa LagunaSpain

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