127292018 How European ration run rational health services: Baglom, France, Germany and Sweden | Healthcare Professionals Network |The Guardian
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How European nations run national health
services
Belgium, France, Germany and Sweden run publicly funded health services similar in scope to the UK's NHS
-but in very different ways
Steve Gold
Wednesday 11 May 2011 09,00 BST
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
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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
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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 asa result.
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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 intoa
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 alll 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.
This article is published by Guardian Professional. Join the Guardian Healthcare Network to
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