What can we learn from other countries about reform in health care?

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At a time of rapid policy change in health care, there is a great thirst for international insight – so what can other countries teach us about health system reform?

At The King's Fund, we are committed to learning from other countries. This commitment is strengthened by our new role as National Lead Institute for the United Kingdom, working with the European Observatory on Health Systems and Policies (a programme of the World Health Organization).

At a launch event for this work we invited speakers from across the country and overseas to debate the English health reforms. Our Dutch speaker, Jan-Kees Heldermann of Radboud University Nijmegen, was inundated with questions on managed competition and its role in the Dutch health system.

Both the Netherlands and the UK have high-performing health systems; they operate with commissioner-provider splits; they have sought to introduce competition into health systems to improve quality and efficiency. And with these similarities we might look to the Netherlands to see how competition is playing out.

However, the Dutch model doesn't provide a total blueprint for the NHS, and the distinctions between the systems of competition in the two countries are also significant. In the Netherlands competition is largely between health insurers rather than between providers, as it is in the NHS. Price competition has also been a notable feature of the Dutch system (and to date has produced mixed results). After some deliberation here in the UK, price competition is not set to feature in the NHS in the near future.

With these differences we cannot generalise and say what works there will work here too. There are, however, some important insights to be gained from the Netherlands. The role of the independent, sector-specific economic regulator in the Netherlands to support competition has created a stronger, more effective system of competition regulation than in other countries, including the UK. Getting Monitor's role right really will be key to the success of these NHS reforms.

Some evidence suggests that providers are confused as to what constitute 'anti-competitive practices' – or collaboration, which has discouraged them from working together. Ensuring that Monitor's role is to promote competition and collaboration will give providers the clarity needed to achieve integration in practice.

Part of the success of the introduction of competition in the Dutch system rests on its consistency in evolving its competition policy for more than 20 years. In contrast, the NHS has experienced several shifts in policy. Perhaps a more evolutionary rather than revolutionary approach is needed here to ensure the new system of economic regulation balances competition and collaboration effectively in the best interest of patients?


Paul Shannon

consultant anaesthetist,
Comment date
02 June 2011
The UK has a lot to learn from other countries. The most revealing index is the European Consumer Powerhouse Health Index. To say the UK has a 'high-performing' health system is misleading; we have a mediocre one - 13th out of 29 in Europe (2008). Holland is top 3 years in a row. All the top ten have insurance-based systems. As the report says, 'Bismarck beats Beveridge every time'! We must wake up from this notion that we're the envy of the world.

Dom Harris

Comment date
03 June 2011
I've been looking around for some good analysis comparing NHS reforms with other publicly funded healthcare models; all of the above is interesting but it would be good to see a full report.

Rich Hamilton

Comment date
06 June 2011
Whilst "European Consumer Powerhouse Health Index" is interesting, it includes as positives things we might question (direct access to specialists). The clincher for me is that it does not consider the level of funding needed to run the system.

The Commonwealth fund publication (Mirror, Mirror 2010) is not perfect either, but at least it points out that Holland spend 30% more per-person on their system than the NHS does, and it ranks the UK as a close second to the Dutch system, and ahead of all the other countries studied.

The bigger point is the design of the rating system depends on your values. Is 'Ease of malpractice litigation important? Level of subsidy of pharma company products? More cataract operations per head of population?' some would see these as signs of failure not success.

Similarly a test for "treatment in 90 days" is a fairly arbitrary pass/fail which the massive achievement of hitting 18 week standards still fails (90 days = 13 weeks)

The subtlety lost in the current debate is that the answer about competition vs integration in relation to care is "it depends". It depends on the capital intensity of the service, (the cost of redundant capacity in the system to achieve choice), the clinical benefits from continuity of care and relationships, and the degree to which service outcomes are transparent to patients, and many more. 'Markets where they help' and skills to determine where that is, are the order of the day.

Claire Mundle

Comment date
08 June 2011
Dear Dom,

In 2006, we produced a report that focused on international perspectives on regulating healthcare:


A number of messages in this report are still worth reflecting on today.

Whilst we have no immediate plans to produce a similar comparative report, we are hoping to look at the experiences of economic regulators in other countries to further inform our thinking about the role that Monitor should adopt. Please do keep an eye out on the site for more information about this.

Best wishes,


fraser kelly

medical and occupational health consultant,
independant consultant in medical project management
Comment date
12 January 2012
Paul is correct
insurance is the only way to go
current UK system has worker A pay tax to pay for healthcare for citizens b,c,d and f.
Worker A is skilled and earns well.
She studies well.
She is proactive.
She proactively leaves UK for Singapore where I live and teach and work, and is taxed at 17% instead of 50%.
Citizens back in uk-no money for healthcare now.
did they actively live a healthy lifestyle-no.
did they save for costs of healthcare-no.
what now?

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