How European nations run national health services

Looking at different countries’ healthcare systems is like looking at the NHS in a circus mirror: the main elements are all there, but it’s a different image. There are differences between almost all countries’ organisational structures, along with the way their ‘insurance’ system is administered, usually for historical reasons. And while European citizens can use other countries’ public healthcare under the European health insurance card scheme, attempts to join systems up (such as patient records) are at an early stage.

An interesting aspect of this is how similar the administration of these countries is to the UK’s pre-1974 NHS structure, which evolved because of county council involvement. English councils will soon be involved in public health, and could have more significant powers depending on how the NHS

What differs, however, is the way treatment is controlled at the point of care, and how the patient pays and is reimbursed. In some countries, this has profound implications for the unemployed or homeless, although most doctors will treat first and organise the paperwork afterwards.

Belgium

Belgium’s healthcare system is rated by Expatica.com, a UK expatriates web site, as having one of the best healthcare systems in Europe. Dating from 1945, its 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.

Also as in France, most citizens also sign up for mutual insurance to top up their healthcare reimbursements (complimentaire).

As in Germany, Belgian citizens can visit any healthcare establishment they wish - quite literally walking in off the street, although referrals from private or practice-linked GPs are increasingly being used, and language pays a major part in choices.

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.

Healthcare insurance is a part of the Belgian social security system, meaning that citizens must join a health insurance fund mutuelle (mutualiti) or ziekenfonds (mutualiteit) and pay through payroll or bank deductions.

Hospitals and GP clinics are private and typically managed by universities, religious organisations or mutuals. Most cities have a choice of a social welfare hospital and a religious hospital.

The former are highly regulated and will treat regardless of the patient’s ability to pay. The latter tend to have a more middle class atmosphere and are generally associated with ‘better’ treatment.

France

Like the UK, France a two-tier healthcare system, with a state-run equivalent of the NHS - Couverture Maladie Universelle (CMU) - and the private sector. In 2000, the World Health Organisation said it ran the best national healthcare system.
In many ways, the CMU operates as a mirror-image of the planned NHS reformed system in organisational terms, with hospitals acting as the centre of healthcare in liaison with the GP practice.

Almost all state health interactions are carried out using a smart card (carte vitale). This contains details of you and your family’s rights to medical treatment and, like the UK driving licence, comes with a paper form - an attestation - that is used to augment the card in identifying citizens to state-run healthcare professionals.

GP visits cost EUR23 and, after your card is swiped, the money is paid back into your bank account by the state, usually within a few days. Currently one euro is ‘voluntarily’ withheld to fund a number of worthy healthcare activities.

Outpatient and pharmacy interactions are similarly smart card enabled, but the carte vitale system reimbursement rate is between 70% and 100%, depending on the type and point of treatment.

Most French citizens belong to a mutual society (mutuelle) that tops up the reimbursement to 100%. The mutual also liaises with the state healthcare operation - the CPAM (Caisse Primaire d’Assurance Maladie) - on reimbursements.

Some citizens are also privately insured, as in the UK, but there are few patients treated privately in the state system, as happens in the NHS when a consultant refers a private patient into the NHS system.

Inpatient treatment is more complex, as the carte vitale is augmented by forms and the paper attestation for treatment in the private sector.

Germany

Germany’s state healthcare system is the oldest in Europe, dating back to the 1880s. Around 15% of people opt out of the state scheme for private health insurance, usually when they are younger, as premiums are lower.

Citizens pay into one of the 300 statutory state sickness funds through their payroll or bank. Payments are around 13% of gross earnings, although citizens can elect to switch funds to save on premiums with government blessing - people can even compare fund rates online.

Some funds operate on a pay-for-treatment-and reimburse basis, but some treatment centres - notably GPs and hospitals - have arrangements with local sickness funds to save patients paying.

Inpatient stay reimbursements are complex and are not based on treatments, a situation that has caused many experts to suggest health reforms (Gesundheitsreform). The German health care reform law (January 2004) simplified a previously highly complex administration, seeking to reduce paper trails and sickness fund premiums as a result.

Comparing healthcare contribution rate is made more complex because accident (Arbeitsunfallversicherung) and long-term care insurance (Pflegeversicherung) is usually bundled with health insurance by many funds.

The Federal Ministry of Health controls all aspects of state healthcare, organised in a similar structure to the pre-1974 NHS in the UK, with the ministry working directly with hospitals and GPs and with local council delegations in many city areas.

German hospitals operate under diverse ownership, with a mixture of state, private, mutual and friendly societies. Germans can visit any GP or specialist they wish - they can even walk into a specialist clinic off the street.

The unemployed are funded separately though the social fund or the AOKs (Allgemeine Ortskrankenkasse), the local funds of last resort, which cover about one-third of the population.

Sweden
Sweden has radically different healthcare model to much of Europe: fully government funded and highly de-centralised. It is 70% funded by local taxes, with the Ministry of Health and Social Affairs establishing principles and guidelines for care at a national level.

But regionally, it is the countries’ 21 councils that effectively control the healthcare system, again showing similarities to the pre-1974 NHS. The councils, known as municipalities are responsible for healthcare provision, particularly where community care and psychiatric services are involved. They are powerful organisations, also running water supplies and social welfare in their areas.

Not all treatment is free at the point of care, though 97% is government-funded. Patients pay a nominal fee at the point of care and, as in the UK, the service is GP-centric. Drug treatments are nominally charged - as in the UK - subject to a capped rate of around £150 per year.

GP visits are also charged at around £12 per visit, although citizens can also visit private doctors at the same rate. A similar fee is levied on hospital outpatient visits. If patients register, they can also qualify for a capped rate of around £70 a year for GP and hospital healthcare. As in Belgium, dentistry is private, and is only partially funded by the state.

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