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A Five-Nation Hospital Survey: Commonalities, Differences, and Discontinuities

Executive Summary
The 2003 Commonwealth Fund International Health Policy Survey found that the ability of hospitals and hospital executives to serve the needs of patients continues to be a major concern of elected representatives, citizens and health care professionals. Compared with the U.S., hospital administrators in Canada, New Zealand, Australia and the U.K. are more satisfied with their systems, but are struggling with greater financial challenges, capacity shortages and inadequate facilities.

Australian efforts to improve the quality of care are comparatively recent, and implementation of national policies remains far from complete. Australian executives, especially those in private hospitals, are more likely than colleagues in other Commonwealth countries to report concerns about losing patients to other hospitals and freestanding health care facilities.

Canada is emerging from a period of fiscal constraint that has seriously affected its hospitals. Canada presents the picture of a publicly governed system in severe financial trouble, struggling with limited capacity and uncertain of its future.

In New Zealand, recent increases in government spending have been preferentially directed towards primary care and public health investments as well as to the hospital sector. New Zealand hospital administrators report the shortest emergency room waits, the absence of diversions, the shortest waits for discharge from the hospital and the greatest facility in communicating with community physicians at the time of discharge.

In governance, the United Kingdom's health care system is almost certainly the most centralized of all the sampled countries. U.K. hospital administrators were less likely than colleagues in any other Commonwealth country to report deficits or losses, and were relatively optimistic about their ability to maintain current services going forward. In general, the U.K. data suggest a system that, while plagued with performance problems, has generated optimism for its ability to improve both in meeting demand for services and in quality and safety.

With its predominantly private and decentralized system, the United States stands apart. Perhaps the most important trend in the U.S. has been the retreat of managed care and a reassertion of the historical authority enjoyed by providers of service, who have been able to increase prices and collections from third parties in recent years. Financially, U.S. hospitals are clearly secure. U.S. hospital executives are most concerned with competition for patients. Malpractice concerns and competition probably explains the reluctance of U.S. executives to release quality data.

The satisfaction of providers and users of care with their national systems does not correlate with national spending levels or with measures of system responsiveness, such as waits for elective care. A common theme among the Commonwealth countries has been an effort to decentralize and integrate their health systems by pushing authority and accountability for health care spending closer to the site of care. Respondents also reported striking agreement across hemispheres and continents that the nursing shortage, which was predicted to be intractable, has eased at least temporarily.

The next few years will provide an important test of the ability of single-payer systems to meet the increasing demands of their populations for elective care. In the end, each system must find its own way toward balancing efficiency and equity in its hospital sector, its health system and its society in general.

Publication Details



A Five-Nation Hospital Survey: Commonalities, Differences, and Discontinuities, David Blumenthal, Christine Vogeli, Lashawn Alexander, et al., The Commonwealth Fund, May 2004