Does hospital competition harm equity? Evidence from the English National Health Service

Richard Cookson, Mauro Laudicella*, Paolo Li Donni

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review


Increasing evidence shows that hospital competition under fixed prices can improve quality and reduce cost. Concerns remain, however, that competition may undermine socio-economic equity in the utilisation of care. We test this hypothesis in the context of the pro-competition reforms of the English National Health Service progressively introduced from 2004 to 2006. We use a panel of 32,482 English small areas followed from 2003 to 2008 and a difference in differences approach. The effect of competition on equity is identified by the interaction between market structure, small area income deprivation and year. We find a negative association between market competition and elective admissions in deprived areas. The effect of pro-competition reform was to reduce this negative association slightly, suggesting that competition did not undermine equity.

Original languageEnglish
JournalJournal of Health Economics
Issue number2
Pages (from-to)410-422
Publication statusPublished - Mar 2013
Externally publishedYes

Bibliographical note

Copyright © 2012 Elsevier B.V. All rights reserved.


  • Economic Competition
  • Economics, Hospital
  • England
  • Healthcare Disparities/economics
  • Humans
  • National Health Programs/statistics & numerical data
  • Poverty Areas
  • Small-Area Analysis
  • Socioeconomic Factors
  • Competition
  • Hospital
  • Inequality


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