The NHS vs Overseas Alternatives

In 2014, the Commonwealth Fund declared that in comparison with the healthcare systems of 10 other countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the US) the NHS was the most impressive overall. The NHS was rated as the best system in terms of efficiency, effective care, safe care, co-ordinated care, patient-centred care and cost-related problems. It was also ranked second for equity.

We take a closer look at other countries and their health service.

Upfront payments: yes

Under France’s state-run equivalent of the NHS, the majority of patients must pay the doctor or practitioner upfront. The state then reimburses them in part or in full. The patient has freedom to choose which doctor or service to visit.

All health transactions centre on a smartcard. A GP visit costs €23 (£17), the Carte Vitale is swiped and the money is paid back into the patient’s bank account within five days. In general, the state reimbursement rate is between 70% and 100%. The poorest people and the long-term sick are covered 100%.

Most people are signed up to a mutuelle, a semi-private insurance body, often related to their job, which tops up the remaining amount to be paid. If a patient is taken to the emergency department of a hospital, for example, they would provide their Carte Vitale, and depending on the health issue, could be reimbursed fully by the state. However, from November 2017 doctors such as GPs will have to waive the upfront fees for all patients, and instead the state and the mutuelle companies will pay doctors direct. At pharmacies, the patient pays upfront but swipes their Carte Vitale. A large number of prescribed medicines are reimbursed between 15% and 100%.

Upfront payments: yes

GP visit in Ireland typically costs €40-€60. However, in 2015 the Irish government abolished charges for children under six while people with a medical card or GP visit card also receive free GP care. In most cases individuals pay for prescriptions from pharmacies capped at €144 per month under the Drugs Payment Scheme. Medical cardholders do not pay for medication but do pay a prescription charge of €2.50 per item (capped at €25 per month per person/family).

Patients are usually referred for secondary treatment by their GP unless they have entered the health system directly through an emergency department. Those attending emergency departments without being referred by a GP are charged €100 (with some exemptions). You are not charged if you are subsequently admitted as an inpatient but may be liable for hospital charges. The charge for an overnight stay in a public bed in a public hospital is €75 per day up to a maximum of €750 in 12 consecutive months.


Upfront payments: yes, but reimbursable

Belgium’s healthcare system quality is largely down to its sponsorship by competing mutuals, and provisioned by a mixture of state and non-profit hospitals. Each mutual is funded by the state, the funding dependent on its membership numbers.

Like the system in France, citizens pay and swipe a health card at the point of care. They are then reimbursed between 50% and 75% of the costs by their mutuelle/mutualiteit scheme. Some GPs and hospitals have local arrangements with mutuals to reduce payments at the point of care.

Almost all dentists in Belgium are private, with only partial patient/state reimbursements complicating the landscape.

The Belgian Ministry of Health also recognises homoeopathy, acupuncture, osteopathy and chiropractic care as reimbursable alternative treatments, subject to the practitioner being a qualified doctor.

Upfront payments: yes

Sweden is ranked third by the Commonwealth Fund, with a high proportion of doctors, above-average healthcare spending, and relatively low prescriptions of drugs.

Patients wishing to see a doctor pay a fee that varies depending on where they live, but usually about 100-200 kronor (£8-£16) for adults. Children pay only if they go to emergency rooms, about 120 kronor. For a visit to a specialist you pay up to 400 kronor and for emergency about 400 kronor. A hospital stay costs 100 kronor a day. You usually pay the same whether you choose a private or public clinic or hospital, as long as the private clinic is connected to the general healthcare system. And most are.

There is a limit to how much you pay for healthcare within a 12-month period. In most regions that is 1,100 kronor, but there are regions where the limit is just 900 kronor. Everything is free after that. Prescriptions are subsidised and you never pay more than 2,200 kronor in a 12-month period.
If you are referred to an expert, you pay a lower fee of about 100 kronor.

Upfront payments: yes, but low

Hundreds of millions of Chinese citizens lost the right to free public healthcare after the Communist party launched its economic reforms drive in the late 1970s.

Today, the cost of a hospital consultation is still relatively low. For those with blue government “social insurance” cards, for example, a trip to Beijing’s Friendship hospital can cost as little 2 yuan (20p). It costs about 100 yuan to be admitted to A&E while a night in a ward sets a patient back about the same.

But the often exorbitant cost of medicine and treatment can be enough to ruin a Chinese family. Government officials say they hope to provide affordable healthcare to every Chinese citizen by 2020 and claim 95% of the population now boasts some kind of medical insurance. But in reality even those who do have insurance find it often fails to cover their bills.

Upfront payments: yes

US hospitals are duty-bound to treat emergency cases. Government spending pays for a surprising share of visits to the doctor and drugs through a patchwork of public programmes. Since Obama’s insurance reforms, the percentage of people who have no cover has fallen to “only” 10% – a mere 33 million people.
For the rest, standards are generally high, sometimes among the best in the world. But no matter how good the insurance policy, few Americans can escape the crushing weight of payments bureaucracy, or the risk-averse medical practices that flow from a fear of lawsuits.

Though the system fosters excellence and innovation in places, the messy combination of underinsurance and overinsurance has left the US with the highest healthcare costs in the developed world and some of the worst overall health outcomes.

Upfront payments: no

Every resident of Japan is required, in principle, to take out public health insurance. Regular employees are typically covered by a work scheme, and are required to pay 20% of their total medical costs at the point of delivery.

Those not covered by their employer – mainly the self-employed and unemployed – must join the national health insurance scheme. Premiums are based on salary, value of property and the number of dependants, and members pay 30% of the cost of inpatient or outpatient treatment – including emergencies – with the government paying the remainder. People over 70 pay 10% of costs.

Medical fees above a certain ceiling – calculated depending on income and age – are paid in full by the government. Fees are waived for uninsured people on low incomes who receive government support.

Both public insurance plans cover a range of services, including hospital care, mental health care, prescription drugs, physiotherapy and, significantly, most dental care.

Upfront payments: no

Spain has a relatively high number of doctors – and a low number of nurses – proportionate to its population, but the amount it spends on healthcare has started to fall amid the economic crisis.

Spain offers free, universal healthcare to anyone resident, legally or illegally, in the country, as well as to tourists and other visitors. Since 2012, undocumented foreigners have been entitled only to emergency care. Some 90% of Spaniards use the system, with about 18% signing up to private healthcare schemes, including many public sector workers who are given the option of free, private care. Most dental and eye care is carried out in the private sector.

The system is decentralised across the country’s 17 autonomous regions and so the quality of care, and in particular access to specialist procedures or units, varies. This leads to a degree of internal health tourism.

Upfront payments: in some cases

In Italy, the national health service offers universal health coverage that is free or low cost at the point of delivery and covers the vast majority of drugs.
It is recognised by independent experts as offering affordable and high quality care, though there are regional differences in the standard of some state-run hospitals, with facilities in northern Italy being considered better than those in the south. Citizens can also buy private insurance, which some do to avoid waiting times for doctors’ visits.

The national insurance scheme is offered to all European citizens, and includes full coverage – paid for by general taxes – of inpatient treatments, tests, medications, surgery, emergency care, paediatrics and access to a family doctor.

The ministry said Italy is also the only country in Europe that allows families to choose a paediatrician for children until age 14 at no charge.

Upfront payments: no

Germany was positioned fifth in the latest Commonwealth Fund rankings, spending more than the EU average on healthcare – but its lengths of stay in hospital tend to be higher than in other countries.

In Germany’s healthcare system anyone residing in the country is required to take out a health insurance scheme. About 85% of the population do this by taking out insurance with one of the country’s 124 non-profit Krankenkassen or “sickness funds”: public insurers, many of whom are small and linked to trade unions. Membership rates are about 15% of monthly salary, half of which is paid by employers.

Those who earn more than €4,350 (£3,300) a month can take out insurance with a private company, an option that is mainly popular with freelancers and the self-employed. For welfare recipients, health insurance membership is covered by local authorities.

Membership covers GP and registered specialists as well as basic dental care. If you are taken to hospital, your public health insurance kicks in once you are charged more than €10 a day, covering inpatient care with the doctor on duty at your nearest hospital. It doesn’t cover private doctors or private rooms at a hospital, homeopathic treatment or more advanced dental treatment.

Since 2013, patients in Germany no longer have to pay a consultation fee of €10 when seeing a doctor. They can now also go straight to a specialist, rather than waiting to be referred by a GP.

Upfront payments: no

UK came first in the latest Commonwealth Fund assessment of healthcare systems around the rich world, but an elderly demographic, the obesity epidemic and alcohol bingeing are all taking their toll. The UK also has the worst cancer outcomes of any rich country.

A mission statement set in 1948 for a universal service free at the point of use is under strain like never before. People are still able to see a GP free of charge – though booking an appointment is becoming harder. It will cost nothing to call out an ambulance and go through A&E, to undergo chemotherapy or major surgery. And yet about 11% of the population prefer to pay for private health insurance.

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