This study compared out-of-pocket healthcare spending in Italy and the UK. It found that Italians paid out-of-pocket for services they could have received publicly more frequently than Britons. This is likely due to different policies around waiting lists - the NHS reduced waits through private sector contracts while Italy allowed doctors to practice privately in public hospitals, prioritizing paying patients. As a result, the Italian system has inequitable access, longer waits for non-paying patients, and promotes privileged access for those who can pay out-of-pocket.

1. THE PREVALENCE OF OUT OF POCKET
ACCESS TO THE ITALIAN AND BRITISH
NATIONAL HEALTH SYSTEMS
G. Domenighetti, P. Vineis, L. Crivelli, I. Bolgiani, C. De Pietro, J. Quaglia
VENICE, 17 November 2006

2. Research aims
• To assess if two systems with great
similarities (universalism, financing
through taxation, regulated access through
the central role of the GP, long waiting
lists) have kept their original postulate of
equitable access to services, regardless of
the citizens’ ability to pay.
• To identify the factors which might explain
the possible differences detected in “out of
pocket” access.

3. Methodology
• Telephone surveys of samples of N=1000 citizens
(above 15 years of age) representing their
respective populations.
• Random Digit Method (CATI).
• 3 surveys (March, June, July 2006).
• Standardized questionnaires (prevalence of “out of
pocket” payments, typology of and reason for
payments, degree of tolerance of waiting lists,
different consumption of services, subjective health
status, chronic illness, private insurance cover etc.).
• Statistical analysis of the differences (OR, age, sex,
having a private health insurance, subjective health
status).

4. 0
20
40
60
80
PREVALENCE OF CITIZENS WHO ENTIRELY PAID OUT OF POCKET FOR SERVICES
WHICH THEY COULD HAVE RECEIVED FREE OF CHARGE OR AT A LOWER COST FROM
SSN / NHS (excluding drugs and dental care)
(ITALY – UK / N=1000 / year 2006)
At least once From 1 to 5 times + than 5 times
%
IN THEIR LIFETIME
IN THE LAST 2 YEARS
78.3
19.6
33.6
15.5
44.8
4.2
60.6
9.8
Source: G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
()
()
() P < 0.000

5. 0
25
50
PREVALENCE OF CITIZENS WHO HAVE PAID ENTIRELY OUT OF POCKET ACCORDING
TO THE TYPOLOGY OF SERVICE BOUGHT THE LAST TIME THEY PAID
(Italy – UK / N=1000 / year 2006)
Diagnostic
exams
Visit by a
specialist
Gynaecological
visit
(women only)
%
27.8
3.1
38.8
5.0
8.1
0.8
2.3
5.2
Source : G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
() ()
() da P < 0.001 a P < 0.000
Surgical
procedure

6. 0
20
40
60
PREVALENCE OF CITIZENS WHO HAVE PAID ENTIRELY OUT OF POCKET ACCORDING
TO THE MAIN REASON FOR THE LAST PAYMENT MADE
(Italy – UK / N=1000 / year 2006)
To have the
earliest access
to the service
To choose the
specialist
Unaware that the
SSN / NHS would
have offered the
service free of
charge
%
49.3
12.4
19.4
1.4 2.5
0.6
7.1
4.5
Fonte: G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
()
()
() da P < 0.013 a P < 0.000
Other reasons

7. 84.4
45.9
10.9
41
2.8 5
1.9 2
0
6.8
0
20
40
60
80
100
PREVALENCE OF CITIZENS’ OPINION ON WAITING LISTS IN THEIR
RESPECTIVE COUNTRIES
(Italy – UK / N=1000 / year 2006)
They are a
major problem
They are
acceptable
The problem
doesn’t really
exist
%
Source : G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
()
()
() da P < 0.001 a P < 0.000
Other No answer
()

8. 15.7
4.6
11.9
3.9 3.8
0.8
0
10
20
YES YES, 1-5 times YES, more than 5 times
PREVALENCE OF CITIZENS TO WHOM A DOCTOR HAS SUGGESTED
PAYING FOR A SERVICE ENTIRELY OUT OF POCKET TO AVOID WAITING
LISTS OR TO CHOOSE THE SPECIALIST
(Italy – UK / N=1000 / year 2006)
%
Source : G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
()
() P < 0.000

9. Source : G. Domenighetti et al. (on-going research)
34.3
12.2
0
20
40
SI
ITALY 86.3%
UK 81.0%
Did the doctor agree to the
request?
YES
%
ITALY
UK
()
() P < 0.000
PREVALENCE OF CITIZENS WHO ASKED THE DOCTOR FOR EXTRA SERVICES
(excluding drugs) DURING THEIR LAST MEDICAL VISIT
(Italy – UK / N=1000 / year 2006)
INDUCTION OF THE SUPPLY

10. 48.3
39.8
19
5.8
17
3.74.4
13.4
0
10
20
30
40
50
78.9
52.9
0
40
80
PREVALENCE OF CITIZENS WHO DECLARE THEY HAVE UNDERGONE
ONE OF THE FOLLOWING DIAGNOSTIC EXAMS IN THE LAST TWO
YEARS
(Italy – UK / N=1000 / year 2006)
At least 1 of the
preceding
(YES)
CT Scan –
MRI
YES
Ultrasound Scan
YES
Bone Density
Scan
YES
Blood test
YES
ITALY
UK
% %
Source : G. Domenighetti et al. (on-going research)
()
()
()
() ()
() da P < 0.03 a P < 0.000

11. 80.4
63.4
17.2
38.3
1.7 2.9
0.7 1.4
0
20
40
60
80
100
PREVALENCE OF CITIZENS WHO THINK IT IS ALWAYS USEFUL, ONLY IN CERTAIN
CASES, OR NEVER USEFUL TO UNDERGO MEDICAL EXAMS IN ORDER TO DIAGNOSE
THE EXISTENCE OF AN ILLNESS IN ADVANCE
(Italy – UK / N=1000 / year 2006)
Always useful Useful only in
certain cases
Never useful
%
Source : G. Domenighetti et al. (on-going research)
ITALY
UK
()
()
(NS)
() P < 0.000
No opinion
(NS)

12. Conclusions (1)
• The important difference between the two
countries in the prevalence of citizens who paid
entirely “out of pocket” for services which they
could have obtained free of charge or at a
lower cost from their respective national health
services (SSN/NHS) seems to be the result of
the adoption of two different policies intended
to solve the problem of waiting lists for access
to elective services which distinguish the two
health care systems.

13. Conclusions (2)
 The NHS has chosen a model based on market
dynamics (increasing the range of choice for the
patient, “pay by results”, etc.) which boosts the
efficiency of the services and of the practitioners
(who do not have the right to practice privately within
the public service in the UK). A complementary offer
has been negotiated with the private sector for the
acquisition of elective surgical services, keeping the
access for all NHS patients free thus decreasing the
waiting lists significantly (from 1999 to 2005 the
number of patients on waiting lists of 6 and more
months was reduced by 85% and of those on lists of
less than 6 months by 2%).

14. Waiting times, spending and incentives
1. Mean waiting times for persons admitted for inpatient surgery. Simple average for hip replacement, knee
replacement, cataract surgery, varicose veins, cholecystectomy, and inguinal and femoral hernia.
2./3. Mean waiting times for cataract surgery (2.) for hip replacement (3.) for the year 2005 (Source: Agenzia
per i servizi regionali – Monitor 17 - 2006).
4. BMJ June 11th, 2005.
Source: OECD Economic Surveys: United Kingdom 2003
2000
Italy3
England4 England4
Italy3
Italy2 Italy2

15. Conclusions (3)
 On the other hand in 1999 Italy gave a significant impulse to
the creation of parallel access within the public service by
means of the right given to practitioners to practise
freelance within the SSN (intramoenia = intramural) thus
creating a privileged “line” of access (without waiting lists or
only short ones and with wider choice) for citizens disposed
to pay for the whole service out of pocket.
 This regulation (which probably explains the high
prevalence of citizens who declared paying wholly “out of
pocket” for services which could have been obtained free of
charge or at a lower cost with the “standard line” of access
to the SSN, compared to Great Britain) highlights an
important problem regarding solidarity and the equity of
access within the public health system in Italy between
citizens disposed (or induced) to pay and those who are
not.

16. Conclusions (4)
The inequity of access could be demonstrated
by the fact that the prevalence of citizens in
Italy who paid for services “out of pocket”
does not seem to indicate any significant
difference in relation to income even if further
analyses are necessary.
It follows that long waiting lists are functional
and congenial to keeping and promoting the
privileged paying way to access to the public
system.

17. Conclusions (5)
 Moreover it can be presumed that for patients not
disposed to pay for privileged access out of pocket, the
waiting lists will not tend to decrease significantly (or else
they will do so more slowly) due to the precedence given
to those who will benefit from priority access to services
thanks to private payment.
 In Italy the significantly higher prevalence of services
induced by explicit patients’ request (34,3% versus
12,2%) and the higher consumption of diagnostic
services (48,3% versus 17,0%) as well as the belief that
it is always useful to do preventive diagnostic exams
(80,4% versus 63,4%) are further important factors
which promote the privileged way and thus the non-
equity of access.