News and Comment

Patient experiences tell a different story about the NHS: Insights from the Commonwealth Fund’s International Health Policy Survey

Monday 18 November 2013


Not a day goes by without another headline suggesting the NHS is in crisis. Rotating through the weekly media are debates about patients’ access to GP services, the over-use of A&E, failing trusts, and quality and safety problems. The overall impression is one of front-line services teetering on the edge of collapse, with unsustainable pressures of near apocalyptic proportions. How can we respond when the whole system seems broken?

Sometimes it is helpful to take a deep breath, step back and gain perspective on the situation by comparing the NHS to health systems of other countries. Each year, like clockwork, the Commonwealth Fund of New York releases its international health policy survey. Now covering patients’ experiences from 11 countries, the survey’s results compare access to care, affordability and use of emergency and specialist services.  Comparing the NHS to other health systems tells a different story than the one playing out in the national media.

So, what can the Commonwealth Fund International Health Policy survey tell us about the NHS?

The NHS provides excellent value for money – it is among the most efficient and equitable health systems in the world. This is largely due to its universal tax-based funding. Rarely do NHS patients delay seeking necessary medical care or skip filling prescriptions because of costs. UK patients do not worry about having to pay medical bills. The only sticking point is dental care, where more limited NHS coverage translates into patients skipping visits or delaying seeking care.

Cost-sharing reduces access to care. In insurance-based health systems, where patient cost-sharing is the norm, cost-related access issues are more common place. The survey results also contain a subtle warning. As the Netherlands experience illustrates, austerity measures that result in increased patient cost-sharing are likely to result in people forgoing care. In 2010, 6% of Dutch citizens reported delays in seeking care; whereas in 2013, the figure rose to 22%. The authors of the Commonwealth Study attribute this to recent changes in the way the Dutch health system is organised and funded.

Access to primary care (e.g., same day or next-day appointments) is a problem for half of NHS patients, so strategies for improving outside of hospital care are clearly needed. We compare unfavourably to some of the other countries when it comes to primary care access, although we are doing better than Canada and the US.  The survey data suggest we could learn much from the experiences of the New Zealand system, which is also a primary care-based health system.

Surprisingly, NHS patients report the best access to care after-hours compared to patients in the other ten countries, with 69% of NHS patients responding that it is “easy getting after-hours care without going to the emergency room”. That is almost twice as good as patients in Canada, France, Sweden and the US.

All health care systems face problems with the use of costly emergency care. The proportion of patients using A&E services in the UK (27% in the past two years) is similar to figures from the Netherlands, New Zealand, Norway and Switzerland. Only the US and Canada stand out as anomalies.

NHS patients are largely satisfied with the NHS (63% say the system “works well, only minor changes are needed), and very few (4%) would suggest radical changes. These results have varied little each time the Commonwealth Fund has conducted its patient survey, every two or three years. Fundamental overhaul of the NHS in the way it is funded or organised is therefore likely to prove unpopular. The view that the NHS is in crisis and about to fail is also challenged by the survey’s results.

The Commonwealth Fund survey paints a rosier picture of the NHS than the one we’re debating. We need to pay heed to the lessons from other countries, and not throw the baby out with the bathwater. Policies that focus on improving primary care and reducing unnecessary use of emergency services make sense in the near term.

What the survey doesn’t comment on is the poor financial outlook of the NHS – the key issue of diminishing resources and a lack of forward investment. How we deal with continuing austerity in the NHS will say a lot about how much we value public spending for healthcare.  In five years’ time, the Commonwealth Fund’s survey could tell a completely different story about patient experiences.