health systems

How well is the NHS doing in international terms and how is it viewed? Joanna Lyall canvasses opinion at home and abroad

Ray Robinson, Professor of health policy at the London School of Economics, he works with the European Observatory on Health Care Systems

'Certainly, from my contacts in Europe and North America, the NHS is not considered the envy of the world. But there is admiration for certain aspects of it. The GP system is seen as clinically efficient and cost effective, and universal access is still admired.

But the practice of delivering services to people when they need them is widely seen to have deteriorated.

Other countries are surprised at the passivity of UK patients over their restricted choice of doctors and hospitals. A couple of years ago, an OECD report said many NHS buildings were more suited to be ancient monuments than for the provision of modern healthcare. The NHS is hopelessly undercapitalised in terms of buildings. And we do not have the level of technology and diagnostic equipment found in other parts of Europe.

Hospitals in Germany, the Netherlands and France are quite different.And the idea of waiting a year for an operation would seem pretty odd to most western Europeans. The US view is that waiting times are to be expected in a socialised system.

Ten years ago, there was still some concept that the NHS was enviable. But I was at an international conference recently when it was claimed that UK life expectancy and infant mortality were on a par with other, often more costly, systems. A German speaker pointed out that while a Trabant and a Rolls Royce would get you from A to B, the journey would be more pleasant in a Rolls. So there are definitely questions about the quality of the journey. But I think the quality of care is generally seen as quite good.

'Dr Charles Swainson Medical director, Edinburgh Royal Infirmary

'No, of course It is not the envy of the world. If it were, other places would copy it - and nobody has.

We have certainly learned to contain costs and we are Europe's leaders in driving down length of stay.

But we are not efficient because people have to wait for treatment - so they get sicker.

'John Wallwork Cardiothoracic surgeon and medical director, Papworth Hospital trust, Cambridge

'It is the curate's egg really. The quality of clinical services is excellent but the infrastructure is terrible and the biggest problem is chronic underresourcing. But our US colleagues are envious of the NHS organisation of transplantation services. I have been in the NHS for 30 years and I would never go abroad. But I do think the workforce in the NHS is exploited. And the government is foolish to think that extra nurses and doctors can be spirited up to meet their plans. Governments always underestimate the chronic shortfalls. And changing the infrastructure every three years doesn't help. I am also a bit concerned about policy being made on the hoof - like health secretary Alan Milburn's announcement that patients will now go abroad for care.Hospitals definitely need rethinking, with outpatients and diagnostic services taken away from the acute hospital and provided in ambulatory care centres that close at night. But it needs a bit of vision to establish that. Overall I think if you are not poor, and time is of the essence, you do not envy the NHS. But if you are poor, and want access to high-quality care, then you do.

It is worth remembering that our infantile mortality rate is much better than that of the US.

'Colin Sullivan Director of NICARE, an NHS consultancy, set up in 1990 in Belfast to provide management and clinical expertise for projects in the developing world

'Looking at it as a training organisation, the NHS is still the envy of the world. The doctors I come into contact with certainly see time in the NHS as a very worthwhile training experience. And the adverse publicity around events in the NHS is confusing for people who trained here and, now back in their own countries, remember it with affection. And the UK has almost led the world in making nursing a graduate profession, I think.

It is important to remember that the developing world is most of the world, and there our universal free access to high-quality care is a source of envy.

I think the dominance of the hospital is a problem, but That is not unique to the NHS.

All the countries we work in have a health hierarchy and the hospital is always at the top.

'Philip Berman Director, European Health Management Association

'Sadly, the predominant view is that the NHS is a system that has severe waiting-list and resource problems, and that while the Beveridge model was hugely significant in the early days, there is little to be learned from current NHS structures.

Perhaps the National Institute for Clinical Excellence and the growing movements towards accreditation would be exceptions to this. The quality of care and medical training are generally admired. But observers do not admire the chronic underfunding and over-centralised bureaucracy.

'Professor Peter Cruse Head of anatomical pathology, Cape Town University, South Africa

'Yes, I would say the NHS is generally envied by South African health workers because it is able to deliver free and universal access to healthcare for patients at point of delivery. It is also regarded as being good value for money (6-8 per cent of GDP) and having high clinical standards and excellent training facilities. To train in the UK and obtain a UK qualification is seen as the high point of any medical career.

South African health staff particularly admire the management of the NHS. Its reputation for being well-managed is often attributed to the fact that there are management training schools for health managers. The calibre of highly qualified executives working for the NHS who are reasonably well paid and who use business methods is said to be responsible for this. NHS managers are perceived to be in touch with business processes and modern business systems.Working for the NHS is generally seen in a better light than, for example, being a public servant in the employ of the health department in South Africa. The salaries and working conditions are also seen as superior to those in South Africa. Access to further training and career advancement are thought to be more readily available. There is wide admiration for the innovative manner in which the NHS has used private capital to finance the building of over 30 new hospitals via the private finance initiative.

But there is a negative view of waiting lists and a lot ofbad publicity, with stories of patients waiting for years for operations and treatment, and so on, and patients being ferried around to numerous hospitals as there are no beds available. But it is recognised that the NHS is addressing these waiting lists proactively - for example, by transferring patients to 'preferred providers' in the private sector.

But we have our problems. A coronary bypass operation here at Groote Schuur Hospital has a waiting list of nine months to a year, and for an appointment to see a specialist in our cardiac clinic the waiting time is four to six months.

Primary care in South Africa is not as wellmanaged or accessible as in the UK and the standards are not as high.Major factors here are the legacies of apartheid, the wide distribution of the rural population and the costs of providing even the most basic healthcare to remote regions, which are sparsely populated. The South African government is busy deliberately redistributing healthcare resources here from the tertiary sector to fund and build the primary sector. 'Better health for all' is the long-term goal.We would do well to model our health service on the NHS, which has much to be admired, especially its GPs.

'Chris Lyons General manager, Letterkenny General Hospital, County Donegal, Ireland. A former NHS management trainee, he worked in the NHS in Northern Ireland for five years before moving to his present post

'Looking from the outside in, I think the NHS has gone through change overload since the Thatcher reforms, and you wonder just what is going on. But I think it is probably still admired for its fairness as it doesn't discriminate on the basis of wealth.

It is definitely ahead in some areas like clinical governance and evidence-based medicine, but not investment in buildings.Health buildings are definitely much more modern in France, Germany, Norway and the US, where I've been recently.

Ireland shares many of the problems of the NHS, such as staff shortages - We have just started to recruit nurses from the Philippines - and waiting lists. But There is a very different culture in the health system here; It is much more a system of empowerment.

The NHS seemed much more bureaucratic and hierarchical. I wouldn't want to go back. And as healthcare is part of the national development plan, it will be getting investment.

'Dr Geoffrey Rivett Author of From Cradle to Grave: 50 years of the NHS . Retired GP and former senior principal medical officer at the Department of Health 1987-1992

'How could countries with access to high-quality inpatient care within weeks envy a country that demands long waits, even for outpatient care? We have just come back from Norway, which is already sending patients to Sweden and Finland to avoid long waits for cold surgery. In 1948 Bevan said patients could go to the hospital they needed. Now we do not even have a national service; It is 90 different contractualised local services. There has been quite a movement towards managed care in the last 15 years. And as a retired consumer, the grassroots view of the NHS is appalling.My wife saw faeces left on the floor for two days at a London teaching hospital, and the way food is provided is terrible. I think Mr Blair should take money from the devil himself, if necessary, to improve the service. And in a country where many people pay£2,000-£5,000 a year for holidays, I think patients' ability to pay for operations such as hernia, cataracts and varicose veins should be explored.

'Marianne Hanning Project manager, department for policy on healthcare, Swedish Federation of County Councils

'We do sometimes envy the clarity of the NHS organisation.We have 20 county councils organising health services. Councillors sit on their boards, so It is more political. I also really envy the amount of research and epidemiological work that goes on in the NHS.

We are also a little astonished about what the NHS manages to provide, given that it gets much less of GDP than in Sweden.We are also impressed by the extent of your primary care.We have GPs, but there is no obligation to consult them to be referred to a specialist. Our greatest problem is shortage of staff.

We are now recruiting doctors from Germany, Spain, Denmark and Poland.We have waiting lists, but nothing like the UK - waits of more than a year for an operation are very rare. And so are hospital rooms with more than six beds.

Another big difference is that doctors who are employed by the hospitals do very little private practice. At the end of the 1970s, it was decided that any doctor who wanted to do private practice would have to have the agreement of the county council. There is a very strong feeling in Sweden that healthcare should be equitable and free.

'Nicholas Jennett Senior health economist, European Investment Bank, Luxembourg, which is owned by the 15 member states of the European Union and provides long-term loans for capital investment projects

'In terms of capital and service planning, the NHS is probably the best in Europe, and financial planning at provider level is also typically very good.Doctors' commitment to management is another advantage. Similarly, the clinical governance initiative - the responsibility of senior managers and clinicians for quality - is admired in Europe.

I think the NHS is also envied for its evidence base - not only in the evidence-based medicine initiative, but also the scrutiny applied to management and policy. The academic and health policy community is more active than in any other country.

But of course there are difficulties.As the NHS plan recognises, there is a significant maintenance backlog for NHS buildings.Other countries in Europe have had more ready access to capital - both in secondary and primary care. The current NHS capital programme - both the publicly funded and the PFI elements - is a great step forward, and the capital planning framework should ensure these resources are used effectively. The local improvement finance trust is also an exciting initiative.

I found it culturally quite strange moving from the NHS to Luxembourg's social insurance-based system of medicine.

After sitting for 20 minutes with the doctor the first time I consulted a GP, I was beginning to think there was something seriously wrong. Being handed a bill as I left the surgery, however, brought me round quite quickly. There is no concept of registration with a family doctor here.We have quickly adopted the practice of consulting different GPs for different purposes.

Perhaps the biggest difference is the absence of a gatekeeper role in health systems like those of Luxembourg.

Many British people living here continue to consult GPs before seeking specialist advice, though we remain free simply to consult a specialist without a referral.