February 2009




Universal healthcare: the European experience

by Michelle Dalton EyeWorld Contributing Editor



As part of an ongoing series over the next several months, EyeWorld will present perspectives from ophthalmologists around the globe regarding their countries’ health care policies

Socialized healthcare has been a staple across most European countries for decades—the United Kingdom’s National Health Service (NHS) celebrated 60 years in July. While most countries allow inhabitants to also have private insurance, those in the public system often face long waiting times to see physicians and limited choices.

The United Kingdom

The NHS covers about 95% of its citizens, with the remainder opting for private insurance, said Richard Packard, M.D., F.R.C.S., F.R.C.Ophth., consultant surgeon, Prince Charles Eye Unit, Maidenhead, United Kingdom. In the United Kingdom, each country’s system operates independently and is politically accountable for its expenditures. A common complaint about the system is “double taxation,” in that those who opt for private insurance are still taxed for contributions to the NHS. The total health budget in England in 2008/2009 is about $188 billion, of which NHS England accounts for $184 billion, according to HM Treasury. Funding for the NHS is from general taxation and as of yet, “there are no copayments but adults between 16 and 60 pay a prescription charge for each prescription of about $14,” Dr. Packard said. The Sight Test Fee in England is about $38, with 13.1 million NHS sight tests carried out in the U.K. during the 2006/2007 fiscal year. According to the NHS, a voucher system is used to supplement spectacles and the like. In his clinic, he sees patients in a “one-stop cataract clinic where a date is set for surgery, and they wait a maximum of four weeks,” he said. In the independent sector, Dr. Packard charges patients directly for which private insurance may help defray the cost for the patient. Wait times are almost nonexistent for patients with private insurance, he added. “Patients wait a maximum of 18 weeks in most parts of the country to be seen and have their treatment, including cataract surgery,” Dr. Packard said. Some diseases, such as cancer, are mandated to be seen in under two weeks, and emergencies must be handled within four hours, he said. Lifestyle procedures, such as LASIK, are not covered, and patients will pay the whole cost. Likewise, treatments deemed ineffective or relatively cost-inefficient are not offered through the NHS. Referrals to specialists (including ophthalmologists) are needed from general practitioners, which were originally designed to be “gatekeepers” to healthcare access. And often, if a patient opts for a medication that not covered by the NHS, even in complex illnesses such as cancer, the NHS will mandate the patient pay out of pocket for the full amount of care. According to the New York Times, officials said allowing patients to pick and choose their treatment would give the wealthy an unfair advantage and undermine the philosophy of the system.


Health insurance is just as likely to be private as public in Ireland, said Arthur Cummings, F.R.C.S.Ed., Dublin, Ireland. More than half of the four million inhabitants in Ireland are on a private network, he said, but services are delivered in public hospitals.

For those in the public system, the ability to contribute to the cost of health care greatly influences access to care and offers universal entitlement to care at a “nominal” user fee, Dr. Cummings said.

Inequities in the system exist, and the private sector is continually undergoing premium increases, inadvertently impacting the public sector, according to a report on the Irish health care system. Most officials consider private insurance to be an integral part of any improvement to overall healthcare service delivery in the country, the report said. The Voluntary Health Insurance Board (VHI), a state-owned insurer, was established in 1957 to offer private health insurance to the wealthiest 15% of the population who were not eligible for public hospital coverage.1 Private hospitals in Ireland are completely funded through private insurance or out-of-pocket payments. Irish patients who wait longer than three months to see a physician can apply to the National Treatment Purchase Fund, which will try to secure a visit in the following six weeks. “The government covers that cost completely. Private facilities are reimbursed as if they’re in the public system. It’s potentially open to abuse, and waiting lists can be longer and longer. The Irish system is in a state of flux,” Dr. Cummings said. “Almost every last cent of income tax the government receives is spent on healthcare.”

To address wait times and funding issues, the government is encouraging younger people to join private insurance, some of which charge a set fee regardless of a patient’s age when they join. Second, the government is altering its employment policies. “There are two types of contracts,” he said. One allows physicians to work in both public and private settings, but “government is now trying to employ people who are only allowed to do public work.” Dr. Cummings did add that the government is paying those who are allowed to work only in the public sector a higher rate than those who can split their time.

“Consultants in the public system can treat private patients in the public hospital and incur no overhead,” he said. Ireland boasts more than 100 hospitals that are fully publicly funded, with a private wing clause, and only 10 fully private hospitals. “At the end of the day, it comes down to your income level,” he said. “If you’re willing to pay a nominal fee, you’ll have a shorter wait. It’s very good service.”

In Ireland, “the public system provides a service irrespective of what it costs. The private facilities can cherry pick and decide certain procedures are not cost effective,” Dr. Cummings said.


Belgian health care is also a combination of public and private systems that began in 1945 and boasts four doctors per 1,000 inhabitants. In 1964, health insurance coverage was extended to the self-employed for major risks only; in 1965, to public sector workers for both major and minor risks; in 1967 to those physically incapable of working; in 1968 to the mentally handicapped, and finally in 1969 to everyone not yet protected (i.e., the whole population), according to a World Health Organization report on the country.2 Officials expect the number of elderly will almost double by 2025, and health care costs are likely to grow at a faster rate than general inflation. “We have a big international community here in Brussels [Belgium] because of the EC. Many people find the quality of health care so high, they return to Belgium to stay because they like the quality and accessibility of medicine,” said Jérôme C. Vryghem, M.D., Brussels.

In Belgium, most surgical procedures are covered by basic social security, he said. “Once a patient has surgery, the doctor can add extra fees. These are usually covered by patients or by the private insurance. Most people have insurance through their company or on their own,” Dr. Vryghem said. In Germany and Holland, restrictions are placed on the number of cataract surgeries that can be performed per surgeon, per year, Dr. Vryghem said, “but in Belgium, the doctors themselves have quite a lot of freedom in the number of surgeries we can perform.” Additionally, the government does not place restrictions on physicians who opt to work in both public and private sectors. The government will decide, however, if the physician is entitled to additional reimbursement from standard fees. “It may be tied to the cost of living increases,” Dr. Vryghem said. Public healthcare covers only what is deemed medically necessary, but special insurances for ex-pats working in Brussels often have LASIK covered, but “regular citizens are not reimbursed for LASIK,” he said. According to Dr. Vryghem, only about 150 ophthalmologists (of 1,000 practicing ophthalmologists) perform refractive surgery, and only two centers have a femtosecond laser, with about 20 centers nationwide.

Belgium also a high ratio of ophthalmologists to residents, Dr. Vryghem said. “The U.K. is low, Holland is low, but we have quite a lot of specialists. All are surgical, and about two thirds are medical ophthalmologists,” he said. The number of trained medical ophthalmologists is “one of the reasons why there’s strong opposition to legalizing optometrists,” Dr. Vryghem said. “The title is not recognized in Belgium. They’re considered to be a menace to medical ophthalmology. It’s completely different in the U.K. or Holland, where the number of ophthalmologists is low and optometrists could lighten the workload.” With the high volume of surgery performed in Beligium, though, Dr. Vryghem said optometrists could be beneficial to the field, as ophthalmologists now have to train their staff to perform simple diagnostic procedures.


Spain is one of the largest countries in Europe, with a population of 39 million and one of the lowest birth rates in Europe. Like other countries, there is both public and private health care, with about 75% of the health care system publicly funded through taxation.

Compulsory sickness insurance was expanded to include the whole population in the mid-1970s. By the late 1970s, the public health care system served more than 80% of the population.3 Like other public health care systems, patients are not allowed physician or hospital choice, and geographic location may play a significant role in wait times to see specialists. The wait time to see an ophthalmologist can be as long as six months, said Angel López Castro, M.D., Madrid, Spain. “If you have a cataract, the only way to have the surgery paid for by the government is to go to a public hospital,” he said.

In areas of the country where the government has determined wait times are excessive, it will contract with private clinics for a fixed price to treat patients. Spanish ophthalmologists are not very well organized, and both public and private pay is low by European standards. In a public hospital, salaries are under 3,000 Euros/month, cataract surgery is reimbursed at a rate of 800 Euros (including hospital costs, IOL, staffing, among other factors), and an initial consultation is reimbursed at 18 Euros, he said. “We are not united,” Dr. Castro said. “The public system needs more ophthalmologists, and salaries need to improve.” Dr. Castro is in favor of a system that allows the patient to choose where to go, with the patient paying the difference between government reimbursements and private physician fees. “The private practice could have cheaper prices because they’d have more volume, and it would reduce the hospital overflow,” he said.


The Italian healthcare system ranks highly on the World Health Organization’s list of countries that provide quality health care services, but many hospitals are overcrowded and underfunded. The Italian government introduced its system in 1980 to cover all citizens. The basic principle of the system is that health is a fundamental right of all citizens, and that the government is obligated to provide that to its citizens, said Matteo Piovella, M.D., scientific director, CMA Outpatient Microsurgery Center, Monza, Italy. In the late 1990s, the health system became federalist, with municipalities and regions exerting more influence over how federal monies were spent.

The Italian eyecare system “is not built on eye doctors, but is based on the optical or private organization that works like a hospital,” he said.

Budgets are set yearly, and once a hospital spends its allocation, “they can’t spend more than they’ve been given,” which makes technology purchasing decisions difficult. “In Italy, 90% of the doctors are in the public system. There are some, like me, that provide private practices where every patient who comes to my office has to pay directly out of pocket for his treatment,” Dr. Piovella said.

Doctors are paid monthly by the public system, regardless of the number of surgeries performed, and most physicians are limited to practicing either in the public or private sector. “There’s an ideological problem for patients to pay more for better quality,” he said. “Today it is possible to get cataract surgery in every region of the country. We believe everyone has the right to be admitted for surgery or eyecare assistance. But the great problem is the economic expense.”

Because hospitals cannot overspend, decisions about newer technologies—such as optical coherence tomography, intravitreal therapy, newer phaco machines, and lenses—are often not determined in a timely manner. “In my opinion, what is hard to get politicians to understand is that the only solution is to introduce copayment system,” Dr. Piovella said. “In my country, about 98% of the doctors are in the public system. But it’s a good balance and a good deal for the citizens, but we need access to better technology.”

Editor’s note: Drs. Packard, Cummings, Vryghem, Castro, and Piovella have no direct financial interest related to their comments.

Contact information

Castro: +34914448230, alopez@laservision.es
Cummings: +353 1 2930470, abc@wellingtoneyeclinic.com
Packard: +442075801074, eyequack@vossnet.co.uk
Piovella: +39 039 38 9498, piovella@piovella.com
Vryghem: +32 475 71 08 71, dr.j.c.vryghem@vryghem.be


1. Colombo F, Tapay N. Private health insurance in Ireland: A case study. OECD Health Working Papers. Published Feb. 12, 2004.
2. World Health Organization. European observatory on health care systems: Health care systems in transition–Belgium. 2000.
3. Rodriguez E, Gallo de Puelles P, Jovell AJ. The Spanish health care system: Lessons for newly industrialied countries. Health Policy Planning. 1999;14:164-173.

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