France and the UK may have different approaches to healthcare delivery, but many of the challenges they face are the same

We were sitting outside a cafe by the Canal St Martin in Paris. I was drinking coffee from a tiny cup. Michel was reading about low patient satisfaction in the UK.

"What I don't understand", he said, "is how can you expect patients to use healthcare services appropriately if people don't feel like they pay for them, at least in part? Why should they really care about the NHS if they don't feel as though it is theirs to care for?"

A little of the creosote from my cup got caught in the back of my throat.

Patient engagement

The NHS is the purest form of collective ownership, I argued. Everybody feels like it belongs to them. It is in our DNA. Services are free at the point of delivery, regardless of what you need, who you are or where you live. We are proud of it.

"But if you don't feel as though you are paying for it, you don't respect it", he said. "Why wouldn't you misuse something if you didn't feel like it was yours?"

"But we do pay for it, through our taxes", I protested. In France, the public is engaged in funding its healthcare. The state pays for 70 per cent and the remaining 30 per cent is covered by contributions made to private insurance schemes, usually through work.

But what about the poor and the unemployed? All their costs are covered by the state, he explained, as are those of children, older people and everybody with one or more long-term conditions. Patient satisfaction is universally high and health outcomes are good. Politicians do not get involved.

My scepticism was ebbing away. The NHS was not utopia, after all.

Challenges all round

But there were challenges facing the French system. Young people did not always see the benefit of signing up. And people who lived just above the poverty threshold and seemed to be worse off overall struggled to pay.

Overall, patients could choose where they accessed services, but Michel admitted the picture was not as rosy as he wished. In reality, patients can choose where they go for surgical interventions. They are quick and lucrative, so the private sector is keen. Longer-term interventions, such as non-surgical treatments for cancer, are not lucrative and tend to be provided by public hospitals. And choice is an urban phenomenon. In rural France, there is little choice because there are few providers.

And choices depend on how much money you pay. For example, if you have a basic insurance package then you have limited comforts in private hospital. The richer you are, the more choice you have.

The French are getting sicker - rates of diabetes, heart disease and depression are soaring - and resources are reducing. Increased patient expectations and a system replete with medics are costly. Over-prescription is common. Last year, the health system overspent by 6bn Euros. Demand has to be reduced.


With little political accountability in relation to health, finding levers is tough. There are few incentives to encourage patients to stay well; the sicker somebody is, the more money doctors are likely to make.

Government-funded bodies, similar to the Healthcare Commission and National Institute for Health and Clinical Excellence, are identifying cost-effective interventions. The government is addressing issues of inequality and poor access. And insurance companies are offering GPs enhanced payments to screen people who are "at risk". The responses are creative, but challenges remain.

Our ideas about health service delivery might be different in the UK and France, but the solution is similar: focusing on prevention will safeguard health in the future and reduce financial burden. How we go about it is open to debate.