Published: 16/09/2004, Volume II4, No. 5923 Page 18

When the EU public was surveyed on attitudes towards its healthcare systems it revealed how elusive 'successful' reform could be, says Anthony Harrison

Impatient for Change European attitudes to healthcare reform Various authors Publisher: Stockholm Network. ISBN 1954766300.£12

This elegantly written booklet reports the results of an international survey of people's attitudes towards their health systems, covering the UK, the Czech Republic, France Germany, Italy, Netherlands, Spain and Sweden.

Each survey report is accompanied by a brief but incisive review of healthcare policy in each of these countries.

Of all the countries surveyed, France is the most satisfied with what is has now - perhaps not surprisingly in view of its selection as the world's bestperforming health system in a recent World Health Organisation report. The French give their system top overall marks - 6.9 out of 10 - and most believe it is better than health systems in other countries.Most also believe that their system performs well against the main criteria of access, convenience, information, choice of doctor and the availability of the latest medicines and technology.

But a substantial majority consider their system needs reform and will get worse in its absence. Jam today, but not tomorrow.

At the other end of the scale in terms of overall marks is Germany, which scores itself at 5.1.Only 4 per cent of those surveyed believe its system will get better in the future in the absence of reform.Nine in 10 believe reform is necessary.Yet Germany is the highest spender of the countries included in the survey and, despite being relatively pessimistic overall, its citizens rate its current performance relatively highly against the specific criteria above.

Spain on the other hand, relatively low down in the spending league, awards itself 6.7 - the third-highest - and displays a relatively low concern about the need for reform, despite a relatively low rating of its system (only the Netherlands is less keen on reform- perhaps because it has already had its fill).

The UK, a low spender at the time of the survey, has the misfortune to combine a poor view of the current performance of its system with a poor view of its prospects and its rating against other countries.

Even so, its citizens award the NHS 5.9 marks out of 10, the fourth-highest rating.

The survey respondents agree on some things. The vast majority in all countries believe that giving users more health information will lead to improvements.Most believe that health professionals are the best source of it. But even though most believe reform is necessary, few place much trust in their politicians.

What do findings like these mean? One implication is that those who argue that adopting the 'European' system would be the cure for the ills of the NHS are mistaken. As one contributor, Helen Disney, points out, there is no 'European' system, only a series of national systems.

True, a distinction can be made between systems financed out of general taxation and those based on insurance schemes. But of the four countries most satisfied with their current level of spending two come from each camp. The four that most support the need for further reform and the (different) four most pessimistic about the future also divide evenly between the two camps.

But equally the survey provides only limited comfort for those who believe big spending increases for the NHS will convince its users that its performance is good enough.

Take waiting as an example.

The government, at least in England, has targeted reductions in waiting times for the past seven years. The recently published NHS improvement plan suggests that waiting will soon be an issue of the past. The data here suggests otherwise.

Higher spenders such as France and Germany score well on waiting times. But the Netherlands and Sweden, both also high spenders, judge themselves to be poor performers in this respect.

Waiting in the UK will only be over when people judge it is, not when government claims it is.

More generally, the notion of a 'solution' to the problems of the NHS is an illusion.As the UK spending level comes closer to the European average or beyond, so will the nirvana of a 'good enough' system move tantalising ahead of it. Enough will turn out never to be enough.

Anthony Harrison is a senior fellow at the King's Fund.