THE STATE OF HEALTH IN EUROPE. An analysis of public attitudes towards health issues in France, Germany, Italy, Spain, Poland and the United Kingdom

Transcription

1 THE STATE OF HEALTH IN EUROPE An analysis of public attitudes towards health issues in, Germany, Italy, Spain, Poland and the United Kingdom May 2016

2 Foreword Health matters to everyone. It affects people s lives in a way that few other policy issues do. It is no surprise that the public hold strong opinions about the state of their health services and the issues that are shaping them. This means that health is a crowded and contested arena. In the face of competing demands and increasing noise, health policy communicators need to be incisive to make an impact. Simply having a deserving cause will not be enough. Health is also increasingly international. Although much of health policy is largely reserved for national governments and this is a power that is carefully guarded a development in one country inevitably influences service delivery in others. Just as disease and ill health do not respect borders, so the impact of policy decisions or public debate is rarely confined to one country. Exploring how public attitudes to health vary across Europe is critical to understanding why health policies differ and, equally, where there may be scope for sharing of ideas or common action. As Incisive Health begins a significant expansion of our international health policy and communications consultancy, we wanted to check the pulse of public attitudes to health across Europe. This report showcases the findings from exclusive polling undertaken in, Germany, Italy, Spain, Poland and the United Kingdom. It reveals some common preoccupations but also some striking differences. For anyone seeking to shape health policy or practice, it will provide important insights. We hope you find it useful. Mike Birtwistle Bill Morgan Sarah Winstone 1

3 Contents Foreword 1 The state of health in Europe at a glance 3 The context for health in Europe 4 Confidence in health services 5 Access to health services 7 Quality of treatment 9 Concern about health conditions 10 Public health interventions 11 Challenges facing health services 12 International collaboration on health issues 13 Conclusion 17 Annex

4 The state of health in Europe at a glance Health expenditure growth has stagnated across Europe People in the UK,, and Spain are proud of their health services. People in Italy and Poland are not People in Italy (6) and Spain (58%) feel that health services have deteriorated Most people are fearful that health services will deteriorate. The UK is most fearful (72%) Italians are the least satisfied (34%) with GP waiting times 2/3 of Germans are happy with the number of doctors compared to only 1/3 of Italians People in the UK, and Germany are the most confident in the quality of their health services Only 1 in 5 people are likely to travel abroad for treatment. Italians are the most likely to travel (36%) 51% of people believe that cancer is the most urgent health problem 1 in 2 people support a tax on sugary drinks to tackle obesity Funding shortage is seen as the biggest challenge facing healthcare systems 62% of people in the UK think that too little is spent on health compared to 29% in Poland 4 in 5 people support greater international collaboration to reduce the cost of medicines 84% of people agree that everyone should have equal access to medicines 67% of British people think that access to medicines should be decided at a national level compared to less than half of Polish people (49%) 3

5 The context for health in Europe There are reasons to be optimistic about health in Europe. We know more about how to prevent, diagnose and treat serious ill health. New techniques and technologies, combined with better evidence about what works in delivering health services, are leading to improved health outcomes. Millions of people in Europe are living longer and have better quality lives as a result. Yet the context for health services is challenging. Whilst health needs and our ability to meet them have continued to grow, spending on health has not. Since the financial crash, growth in expenditure on health has broadly tracked economic growth across Europe, contrasting with the pre-2008 situation when growth in health spending outpaced growth in the rest of the economy. 1 Figure 1 Stagnation in the share of GDP spent on health services Expenditure on healthcare as a share of Gross Domestic Product (GDP) Percentage of GDP Germany Italy Poland Spain United Kingdom OECD Average Health expenditure growth has stagnated across Europe Health policymakers need to understand how public attitudes in different countries have responded to the growing gap between health need and health funding. In order to understand public attitudes to health across Europe, as well as how they vary between countries, Incisive Health has commissioned exclusive public polling in six major European countries: Germany Italy Poland Spain The United Kingdom (UK) Questions were designed to probe attitudes to a range of issues, including: Confidence in health services and levels of optimism about their future Access to health services and staffing levels The biggest health problems facing countries Challenges facing health services The role of international collaboration on health Populus 2 conducted online polling of over 1,000 adults in each country, between 22 and 30 March Data were weighted in terms of age, gender and region to be representative of all adults, aged over 18 years of age, from these countries. All questions were translated into the relevant national language for each country and tested for cultural relevance. Tables of the polling results are included in Annex 1. 4

6 Confidence in health services People in many European countries express pride in their health services, as shown in Figure 2, with over half of respondents in the UK (59%), Spain (53%) and (51%) agreeing that they are proud of the quality of services in their country. This contrasts with attitudes in Poland where only 7% of people agreed. Figure 2 Variations in pride in health services I am proud of the quality of health services 8 74% Net agreement % 15% 39% 23% Germany Italy 53% 7% Poland 53% 23% Spain 59% UK 15% People in the UK,, and Spain are proud of their health services. People in Italy and Poland are not Net agreement Net disagreement Interestingly, pride does not necessarily correlate with belief about the relative quality of health services, as shown in Figure 3. In Germany, for example, more than half (51%) believe that health services in other countries are worse, yet only 39% are proud of their health services. In the UK, 59% are proud of their health services, but a much lower proportion (31%) believe that health services in other countries are worse. Figure 3 Contrast between pride in health and belief in quality 8 Net agreement % 51% 51% 39% 22% 7% 7% 42% 53% 31% 59% Germany Italy Poland Spain UK Net agreement with the statement Health services in other European countries are worse Net agreement with the statement I am proud of the quality of health services Respondents in Poland report very low levels of pride in their health services (7%), as well as a widespread belief that services in other countries are of a higher quality. Barriers to access to public healthcare provision such as long waiting times have led to an extensive use of private healthcare providers in Poland. Although pride in the quality of health services across many countries is high, fears over quality exist: many more people feel that quality has deteriorated over the past year than feel it has improved, as set out in Figure 4. Concerns about deterioration in quality are particularly apparent in Italy (6) and Spain (58%). 5

7 Figure 4 Belief that quality is deteriorating Perceptions of change in the quality of health services over the past twelve months 8 Net agreement % 15% 31% 14% 6 12% 36% 13% 58% 15% 45% 15% People in Italy (6) and Spain (58%) feel that health services have deteriorated Germany Italy Poland Spain UK Net agreement with the statement The quality of health services has deteriorated in the last 12 months Net agreement with the statement The quality of health services has improved in the last 12 months If most people believe that services have deteriorated, then there is little optimism that there will be improvement, as set out in Figure 5. In every country there is a majority of people who are fearful that services will get worse in the future. People in the UK (72%) and Italy (71%) are most fearful about deterioration, whereas in Spain and Poland only half (5 and 51% respectively) of respondents feel that services will get worse and in Spain there is a relatively high level of optimism that services will improve. Figure 5 In most countries the majority of people are fearful for the future of health services Optimism and pessimism about health services in the future Net agreement % 67% 31% 61% Germany 26% Italy 71% 31% 51% Poland 49% 5 Spain 35% UK 72% Most people are fearful that health services will deteriorate. The UK is most fearful (72%) Optimistic services will improve Fearful that services will deteriorate 6

8 Access to health services The ability to access healthcare easily and when it is needed remains a key indicator of the quality of health services overall. People in every country are more satisfied with waiting times for general practice than they are for hospital appointments, as Figure 6 shows: Figure 6 Variations in satisfaction with waiting times for primary and secondary care services Satisfaction with GP and hospital appointment waiting times % 32% 52% 34% 14% 39% 15% 49% 43% 27% Italians are the least satisfied (34%) with GP waiting times Germany Italy Poland Spain UK Waiting time to attend GP appointment Waiting time to attend hospital appointment In relation to waiting times to book an appointment at general practice specifically, there was much variation in attitudes between countries: in the UK and Poland, for example, just 42% of people were satisfied with the average waiting time to book an appointment at their local general practice comparing unfavourably with Italy and Spain (both 46%), Germany (62%) and (63%). Figure 7 Variations in satisfaction with average waiting time to book an appointment at local GP Satisfaction with average waiting time to book an appointment at local GP % 62% 46% 42% 46% 42% Germany Italy Poland Spain UK Net satisfaction We asked about staffing levels in both hospitals and general practice. In respect of general practice, people in Italy are the least satisfied with only 36% expressing satisfaction with the number of doctors and 23% with the number of nurses, as set out in Figure 7. Respondents in Germany were most satisfied with numbers of doctors and nurses (64% and 6 respectively). It is notable that respondents in had relatively high levels of satisfaction with numbers of doctors (6) but relatively low levels of satisfaction with the numbers of nurses (35%). 7

9 Figure 8 Public satisfaction with staffing levels in general practice Satisfaction with workforce provision in general practice % 6 58% 53% Net satisfaction 4 35% Germany 36% Italy 23% 39% 43% Poland 45% 44% Spain UK 2/3 of Germans are happy with the number of doctors compared to only 1/3 of Italians Number of doctors Number of nurses Figure 8 shows that levels of satisfaction with the availability of doctors and nurses in hospitals is somewhat lower, mirroring the pattern found in satisfaction with waiting times. (38% for doctors and 35% for nurses) and Spain (37% and 35% respectively) have the highest levels of satisfaction with staffing levels. As with general practice, satisfaction levels with the number of doctors and nurses broadly track each other, with one clear exception: in Germany, satisfaction with the number of doctors (31%) is significantly in excess of satisfaction with the number of nurses (22%). Figure 9 Public satisfaction with staffing levels in hospitals Satisfaction with staffing provision in hospitals 6 Net satisfaction 4 38% 35% 31% 22% 28% 25% 23% 22% 37% 35% 32% 32% Germany Italy Poland Spain UK Number of doctors Number of nurses 8

10 Quality of treatment Public confidence in the quality of treatment for serious or life threatening conditions is remarkably similar in the UK (76%), (75%), Germany (73%) and Spain (72%). Perceptions are very different, however, in Poland () and Italy (51%), as set out in Figure 10. Figure 10 Confidence in the quality of treatment for serious conditions Do you feel confident that if you had a serious or life threatening illness you would be able to receive the best treatment for your condition in your country? 8 75% 73% 75% 72% 76% Net confidence % 51% 47% 25% Germany Italy Net confident 25% Poland Spain Net not confident UK People in the UK, and Germany are the most confident in the quality of their health services Although the EU Cross-border Healthcare Directive enables EU citizens to choose to receive a health service in another member state, there is no correlation between levels of confidence in a country s own healthcare system and willingness to travel, as shown in Figure 11: Figure 11 8 Comparison between levels of confidence in healthcare system and willingness to travel to another country for treatment 75% 6 47% 4 36% 25% 27% 22% 23% 25% 19% 13% 15% Germany Italy Poland Spain UK Net disagreement with the statement I am confident in the quality of health services Net likelihood to travel to another country for specialist treatment Only 1 in 5 people are likely to travel abroad for treatment. Italians are the most likely to travel (36%) The chart shows that over a third (36%) of Italian respondents indicated that they consider themselves to be likely to travel, perhaps reflecting the relative lack of confidence in the ability of services in Italy to provide the best treatment. However, only just over a quarter (27%) of Polish respondents suggested they would be likely to travel, despite the fact that only one in five expressed confidence in services in Poland. 9

11 Concern about health conditions Across the six countries we surveyed, more than half of respondents (51%) feel that cancer is the most urgent health issue facing their country, and respondents in every country identified cancer as being the most urgent issue. and Spain (both 61%) had the highest level of concern on cancer, with the UK (34%) and Germany having the lowest level of focus (42%). Figure 12 Which of the following conditions is the most urgent health problem facing your country today? 7 6 UK Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other 3 1 Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other 51% of people believe that cancer is the most urgent health problem 7 6 Germany 7 6 Italy Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other 7 6 Poland 7 6 Spain Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other Cancer Obesity Heart disease Mental illness Diabetes Dementia Smoking HIV/AIDS Liver disease Arthritis Other 10

12 The level of prioritisation afforded to cancer may be a reflection of its health impact. Cancer has now overtaken cardiovascular disease as the leading cause of premature death in 17 out of 28 EU member states, 5 and three Europeans die every minute as a result of cancer. 6 Cancer is also a health policy priority: each of the countries included in our study has developed a strategy to improve cancer outcomes 7 and, at an EU level, progress on cancer is being driven through the Joint Action on Comprehensive Cancer Control (CANCON) Figure 12 sets out the differing priorities identified in each country. Heart disease was the second most urgent problem identified in Poland (17%), (11%), Italy (1) and Spain (8%). Mental illness was the second highest priority in Germany (18%) and the joint third highest priority in the UK (11%), along with dementia. The level of prioritisation given to mental health is reflected in the commitments made in both Germany and the UK to increase expenditure on mental health services and to encourage greater integration with community services. 9 It is striking that obesity was identified as the second most urgent issue in the UK (27%) and the third most urgent issue in Germany (14%) and Poland (11%). This may be a reflection of the fact that the UK has the highest level of obesity in Western Europe. 10 Public attention has also been focused on the issue through high profile campaigns by celebrity chef Jamie Oliver, 11 leading to political declarations that rising rates of childhood obesity are a national emergency. 12 Public health interventions Across our six countries, just over half (53%) of respondents suggest that they would be likely to support a tax on sugary drinks in order to tackle obesity, as set out in Figure 13. Germany (44%) and Poland (49%) were the only countries where a majority of respondents did not indicate that they were willing to support such a tax. Respondents in the UK were most positive (63%) about the introduction of a sugar tax. This may reflect public debate on the issue, given that the UK Government announced its intention to introduce a sugar tax in the March 2016 Budget just before our polling was conducted. Figure 13 Attitudes towards a sugar tax 1 in 2 people support a tax on sugary drinks to tackle obesity How likely or unlikely would you be to support a tax on sugary drinks order to tackle obesity? % 43% 44% 51% 54% 42% 49% 43% 56% 39% 63% 31% Germany Italy Poland Spain UK Net likely Net unlikely 11

13 Challenges facing health services Figure 14 Perceptions of the biggest challenge facing health services UK Shortage of funding Staffing shortages Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other Shortage of funding Staffing shortages Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other Funding shortage is seen as the biggest challenge facing healthcare systems 5% 1 15% 25% 3 35% 5% 1 15% 25% 3 35% Germany Italy Shortage of funding Staffing shortages Shortage of funding Staffing shortages Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other 5% 1 15% 25% 3 35% 5% 1 15% 25% 3 35% Poland Spain Shortage of funding Staffing shortages Shortage of funding Staffing shortages Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other Waiting times for treatments Too much bureaucracy Late diagnosis of life threatening illness Quality and safety of healthcare Pressure of accident and emergency services Poor access to effective medicines Poor access to GPs Other 5% 1 15% 25% 3 35% 5% 1 15% 25% 3 35% 12

14 Across the six countries in our study, a shortage of funding is identified as the biggest challenge (18%), followed closely by staffing shortages (17%) and waiting times (16%). However, Figure 14 shows that the issues identified vary significantly according to country. Funding is perceived as the biggest challenge in the UK (23%) and Spain (24%). Staffing shortages is the top issue in (32%) and Germany (31%), whereas waiting times is the top issue in Italy (26%) and Poland (28%). In Germany and the most prevalent view is that their country spends about the right amount on health services (41% in each country). In all other countries the most prevalent view is that they spend too little. The UK (62%) and Spain (53%) are the only countries in the study where the majority of respondents feel that their country spends too little on healthcare, as set out in Figure 15. Across the six countries 44% of respondents feel their country spends too little, whereas 19% feel they spend too much and 29% feel they spend about the right amount. Figure 15 Views on health spending We spend too little on health 8 Net agreement % 62% 53% 46% 34% 29% Germany Italy Poland Spain UK 62% of people in the UK think that too little is spent on health compared to 29% in Poland Net agreement International collaboration on health issues There is strong support for the concept of equal access to effective medicines across Europe, irrespective of country of residence. Overall, 84% of respondents agreed with this statement. However, there are variations in attitude, as set out in Figure 16. The highest levels of support are observed in Poland (92%) and Italy (91%) the countries that express the lowest levels of confidence in the likelihood of receiving the highest quality care in their own country. The sentiment attracts significantly less support in the UK, where less than two thirds (62%) of respondents agreed. There are also very high levels of support for international collaboration to reduce the cost of medicines, as set out in Figure 17. Agreement with this concept is highest in Spain (93%), Italy (91%) and Poland (9). The UK has the lowest level of support, but even then, four out of five (8) respondents agree with the idea. This finding will be interesting to policymakers, given recent efforts to jointly procure medicines. Historically, such efforts have been limited to vaccines and other medicines that might be used in the event of a pandemic or other serious cross-border threat. 13 More recently, however, the Netherlands and Belgium have announced that they will work together on the procurement of orphan medicines, building on cross-border collaboration in recent negotiations on hepatitis C treatments

15 Figure % Support for equal access to effective medicines Do you agree that the people of Europe should have equal access to effective medicines, irrespective of where they live? 85% 91% 92% 88% Net agreement 6 4 2% 62% 13% 4% 2% 2% 4% Germany Italy Poland Spain UK Net agreement Net disagreement Vytenis Andriukaitis, European Commissioner for Health, has already signaled his desire to his desire to make further progress on collaboration on medicines procurement, saying on 17 February 2016: The Commission would be happy to help [member states] buy treatments together and We have to move forward towards a European solution [on health technology assessment]. 15 Figure 17 Support for joint action to reduce the cost of medicines Countries should work together to get a better deal on the cost of medicines Net agreement % 3% 85% 91% 9 93% 8 2% 1% 2% 1% 1% Germany Italy Poland Spain UK 4 in 5 people support greater international collaboration to reduce the cost of medicines Net agreement Net disagreement There is also strong agreement with the concept of working together on the assessment of the effectiveness of medicines, as set out in Figure 18. Support was highest in Spain (88%) and Italy (79%). It was notably lower in the UK, with 44% of respondents agreeing with the idea and disagreeing. 14

16 Overall, this finding will offer encouragement to the Dutch Presidency of the EU, which has made greater collaboration on access to medicines policy a priority, 16 as well as those leading the EUnetHTA programme, which seeks to increase the use, quality and efficiency of joint [Health Technology Assessment] HTA work at European level. 17 Joint Action 3, which started work in Spring 2016, is intended to translate previous collaborative pilots into routine cooperation between national HTA bodies. 18 Figure 18 Support for joint assessments on the effectiveness of medicines Assessments of the effectiveness of medicines should be made at a European level to reduce red tape Net agreement % 7% 68% 9% 79% 6% 73% Germany Italy Poland Spain UK 7% 88% 2% 44% 84% of people agree that everyone should have equal access to medicines Net agreement Net disagreement Moves towards a pan-european approach to health technology assessment will inevitably conflict with a desire to see such decisions taken nationally: more than two-thirds of respondents in the UK (67%), for example, wished to see national control maintained in respect of these decisions (in marked contrast to Poland, where just 49% supported national control). Figure 19 Support for national control over decisions on access to treatments Decisions on access to treatments should be decided by national governments and not at a European level Net agreement % 13% 67% % 53% 22% 23% 16% 16% 6% Germany Italy Poland Spain UK 67% of British people think that access to medicines should be decided at a national level compared to less than half of Polish people (49%) Net agreement Net disagreement 15

17 Another area of potential collaboration that has attracted controversy is in the collection and use of personal health information for research purposes, with the European Parliament having sought to amend data protection regulations in a way that would have had the effect of severely restricting the use of personal data for scientific research purposes where specific and explicit consent had not been given. The EU General Data Protection Regulation (GDPR), which will replace the current EU Data Protection Directive in 2018 and introduce a revised EU legal framework for data protection, adopts a somewhat more permissive approach than that initially advocated by the Parliament. The GDPR allows for research without consent where permitted by member state law. It also introduces a new right to object to the use of personal data for research purposes and then further allows member states to constrain this right to object. Its provisions in relation to the use of personal data for research purposes anticipate the need for further domestic legislation. This approach appears to be more in line with public sentiment, as revealed by our polling. Despite controversies over access to a variety of personal data, Figure 20 shows broad and high levels of support for reducing restrictions that might impede research. Even in, which has the lowest levels of support, nearly two thirds (64%) of respondents agree with the statement that health authorities need to do all they can to cure diseases and this includes cutting red tape on the use of my personal health information to help research. Figure 20 Attitudes towards the use of personal health information in research Health authorities need to do all they can to cure diseases and this includes cutting red tape on the use of my personal health information to help research Net agreement % 7% 85% 85% 76% 78% 7 4% 5% 2% 5% 7% Germany Italy Poland Spain UK Nearly two thirds of people (64%) polled are happy for their personal data to be shared to support medical research Net agreement Net disagreement 16

18 Conclusion Health is an issue that attracts strong views and debates and it will always be shaped by national circumstances, cultures and traditions. Our polling shows that national control over health policy remains fiercely guarded. Yet the healthcare world is also getting smaller. The days when health policy could be developed in splendid isolation are over. Key aspects of health research, knowledge, technology, healthcare professionals and disease itself are internationally mobile. But so are the ideas, opinions and controversies that shape the health debate, the formulation of policy and ultimately the delivery of services. Health policy and delivery is always driven by, or at least must respond to, the opinions of the people who will use health services. This report reveals that the concerns of people across Europe are similar, but that there are important nuances which anyone seeking to shape the health environment must understand. Because few issues touch on people s lives in the way that health does, it will always be a contested and controversial area of policy. In an era when it is easier than ever to make contact with the people who matter, it is harder than ever to have your voice heard (let alone listened to). Tried and tested quickly becomes tested but tired. Doing what you have always done will at best get you the results you have always got. In today s fast moving, increasingly stretched and noisy healthcare environment it might get you considerably less. In short, you have to be incisive to make an impact. This is why Incisive Health is significantly expanding our international consultancy practice. We know how to cut through the noise and competing priorities to deliver results that enhance our clients businesses and reputations and, ultimately, improve healthcare for patients. Our skills health specialism and expertise, creativity in communications, ambition and rigour in delivery are now being applied in a broader context, shaping the dynamics of health in many different countries. We look forward to working with health services, clinicians, the life sciences industry and most importantly patients to shape the future of health, both internationally and within countries, delivering the results which matter most: better, more responsive services, creating better health. 17

19 Annex 1 results tables Demographic breakdown of people polled Gender Age Country All Male Female UK Germany Italy Poland Spain Unweighted base Weighted base % 13% % 12% 1 9% 1 8% % 14% % 17% 14% 18% 19% 16% % 19% 19% % 18% 19% 19% 21% % 18% 16% % 18% 18% 16% 15% 19% % 16% 14% % 15% 14% 14% 18% 14% % 25% 18% % 21% 23% 23% 19% 22% Average age Question 1 To what extent do you agree or disagree with each of the following statements about the quality of health services in...? The quality of health services has improved in the last 12 months NET: Agree % 15% 15% 14% 12% 13% 15% Strongly agree (+2) % 3% 2% 2% 2% 2% 4% Slightly agree (+1) % 12% 13% 12% 1 11% 11% Neither agree nor (0) disagree % 35% 37% 44% 25% 29% 29% Slightly disagree (-1) % 26% 28% 26% 3 29% 3 Strongly disagree (-2) % 16% 1 32% 25% 24% NET: Disagree % 41% 44% 36% 61% 54% 54% Don't know % 9% 4% 6% 2% 4% 2% Mean Standard deviation Standard error

20 The quality of health services has deteriorated in the last 12 months NET: Agree % 45% 43% 31% 6 36% 58% Strongly agree (+2) % 16% 12% 6% 23% 11% 21% Slightly agree (+1) % 29% 31% 25% 37% 25% 37% Neither agree nor (0) disagree % 29% 32% 37% 26% 36% 24% Slightly disagree (-1) % 12% 15% 1 18% 1 Strongly disagree (-2) % 4% 5% 5% 3% 5% 7% NET: Disagree % 17% 25% 13% 22% 17% Don't know % 9% 4% 6% 2% 6% 1% Mean Standard deviation Standard error I am optimistic that health services will improve in the future NET: Agree % 35% 25% 31% 26% 31% 49% Strongly agree (+2) % 1 4% 5% 4% 3% 15% Slightly agree (+1) % 25% 21% 25% 22% 28% 33% Neither agree nor (0) disagree % 25% 26% 3 22% 25% 23% Slightly disagree (-1) % 25% 3 28% 3 25% 18% Strongly disagree (-2) % 11% 15% 9% 21% 12% 8% NET: Disagree % 35% 46% 37% 51% 37% 27% Don't know % 5% 3% 2% 1% 8% 1% Mean Standard deviation Standard error

21 I am fearful that health services will deteriorate in the future NET: Agree % 72% 67% 61% 71% 51% 5 Strongly agree (+2) % 31% 19% 3 14% 13% Slightly agree (+1) % 41% 47% 42% 41% 37% 36% Neither agree nor (0) disagree % 14% 17% 21% 17% 22% 25% Slightly disagree (-1) % 8% 1 13% 9% 18% 14% Strongly disagree (-2) % 2% 3% 3% 3% 4% 8% NET: Disagree % 11% 13% 17% 12% 22% 22% Don't know % 4% 3% 2% 1% 6% 3% Mean Standard deviation Standard error I am proud of the quality of health services NET: Agree % 59% 51% 39% 7% 53% Strongly agree (+2) % 8% 7% 3% 2% 16% Slightly agree (+1) % 36% 42% 33% 17% 5% 37% Neither agree nor (0) disagree % 24% 33% 35% 26% 18% 24% Slightly disagree (-1) % 9% 1 17% 26% 28% 15% Strongly disagree (-2) % 6% 5% 6% 28% 46% 8% NET: Disagree % 15% 15% 23% 53% 74% 23% Don't know % 2% 1% 3% 1% 1% * Mean Standard deviation Standard error

22 Health services in other European countries are better NET: Agree % 25% 22% 15% 55% 73% 37% Strongly agree (+2) % 7% 4% 3% 19% 31% 13% Slightly agree (+1) % 18% 17% 12% 36% 42% 24% Neither agree nor (0) disagree % 26% 33% 3 25% 15% 26% Slightly disagree (-1) % 16% 25% 33% 11% 3% 18% Strongly disagree (-2) % 9% 11% 11% 2% 2% 12% NET: Disagree % 25% 36% 44% 13% 5% 3 Don't know % 24% 9% 11% 7% 7% 6% Mean Standard deviation Standard error Health services in other European countries are worse NET: Agree % 31% 36% 51% 22% 7% 42% Strongly agree (+2) % 1 7% 11% 3% 1% 14% Slightly agree (+1) % 21% 29% 4 19% 6% 28% Neither agree nor (0) disagree % 25% 34% 27% 34% 19% 24% Slightly disagree (-1) % 15% 11% 9% 19% 33% 15% Strongly disagree (-2) % 6% 9% 3% 16% 31% 12% NET: Disagree % 34% 65% 28% Don't know % 24% 1 1 9% 1 7% Mean Standard deviation Standard error

23 Question 2 To what extent are you satisfied or unsatisfied with each of the following aspects of the healthcare services in your country? Number of doctors working at your local GP NET: Satisfied % 6 64% 36% 39% 45% Very satisfied (+2) % 19% 14% 18% 4% 4% 8% Fairly satisfied (+1) % 39% 45% 46% 32% 34% 37% Neither satisfied (0) nor unsatisfied % 17% 19% 21% 35% 28% Fairly unsatisfied (-1) % 12% 13% 11% 18% 24% 19% Very unsatisfied (-2) % 6% 6% 2% 7% 11% 6% NET: Unsatisfied % 18% 18% 13% 25% 35% 25% Don't know % 7% 3% 2% 4% 6% 2% Mean Standard deviation Standard error Number of nurses working at your local GP NET: Satisfied % 53% 35% 6 23% 43% 44% Very satisfied (+2) % 17% 6% 15% 2% 4% 7% Fairly satisfied (+1) % 37% 29% 45% 21% 38% 37% Neither satisfied (0) nor unsatisfied % 21% 31% 24% 39% 23% 32% Fairly unsatisfied (-1) % 9% 9% 8% 16% 15% Very unsatisfied (-2) % 4% 6% 2% 1 8% 7% NET: Unsatisfied % 13% 15% 1 31% 25% 21% Don't know % 6% 8% 9% 3% Mean Standard deviation Standard error

24 Number of doctors working at your local Hospital NET: Satisfied % 32% 38% 31% 28% 23% 37% Very satisfied (+2) % 7% 5% 6% 3% 1% 7% Fairly satisfied (+1) % 24% 34% 25% 24% 21% 29% Neither satisfied (0) nor unsatisfied % 22% 26% 3 33% 23% 27% Fairly unsatisfied (-1) % 15% 18% 22% 25% 25% Very unsatisfied (-2) % 6% 6% 5% 11% 11% 8% NET: Unsatisfied % 19% 21% 23% 33% 36% 33% Don't know % 28% 15% 17% 6% 19% 4% Mean Standard deviation Standard error Number of nurses working at your local Hospital NET: Satisfied % 32% 35% 22% 25% 22% 35% Very satisfied (+2) % 7% 4% 3% 2% 2% 6% Fairly satisfied (+1) % 25% 31% 19% 23% 29% Neither satisfied (0) nor unsatisfied % 21% 24% 27% 33% 25% 31% Fairly unsatisfied (-1) % 15% 16% 24% 23% 24% 22% Very unsatisfied (-2) % 5% 7% 1 12% 11% 7% NET: Unsatisfied % 23% 35% 36% 35% 29% Don't know % 26% 18% 17% 7% 19% 5% Mean Standard deviation Standard error

25 The average waiting time to book an appointment at your local GP NET: Satisfied % 63% 62% 46% 42% 46% Very satisfied (+2) % 14% 22% 1 7% 12% Fairly satisfied (+1) % 29% 43% 4 36% 35% 35% Neither satisfied (0) nor unsatisfied % 14% 14% 17% 23% 17% 21% Fairly unsatisfied (-1) % 21% 14% 14% 17% 25% 22% Very unsatisfied (-2) % 19% 8% 5% 13% 14% 1 NET: Unsatisfied % 23% 19% 3 39% 33% Don't know % 4% 1% 1% 1% 2% 1% Mean Standard deviation Standard error The average waiting time to attend an appointment at your local GP NET: Satisfied % 43% 56% 52% 34% 39% 49% Very satisfied (+2) % 14% 14% 14% 6% 7% 12% Fairly satisfied (+1) % 29% 42% 38% 28% 33% 36% Neither satisfied (0) nor unsatisfied % 17% 16% 24% 17% 21% Fairly unsatisfied (-1) % 22% 19% 19% 26% 21% 21% Very unsatisfied (-2) % 13% 8% 8% 16% 21% 9% NET: Unsatisfied % 36% 27% 27% 42% 42% 3 Don't know % 5% 1% 1% 1% 2% 1% Mean Standard deviation Standard error

26 The average waiting time to book an appointment at your local hospital NET: Satisfied % 25% 28% 25% 13% 19% 21% Very satisfied (+2) % 4% 2% 5% 2% 2% 5% Fairly satisfied (+1) % 26% 11% 17% 17% Neither satisfied (0) nor unsatisfied % 21% 25% 18% 17% Fairly unsatisfied (-1) % 23% 29% 22% 32% 29% 34% Very unsatisfied (-2) % 14% 9% 36% 22% 23% NET: Unsatisfied % 37% 43% 32% 68% 52% 58% Don't know % 8% 19% 1% 12% 1% Mean Standard deviation Standard error The average waiting time to attend an appointment at your local hospital NET: Satisfied % 27% 32% 14% 15% Very satisfied (+2) % 5% 4% 3% 1% 1% 3% Fairly satisfied (+1) % 22% 28% 17% 13% 13% 17% Neither satisfied (0) nor unsatisfied % 21% 23% 17% Fairly unsatisfied (-1) % 25% 27% 26% % Very unsatisfied (-2) % 12% 14% 33% 27% 22% NET: Unsatisfied % 41% 63% 57% 58% Don't know % 15% 8% 16% 2% 11% 2% Mean Standard deviation Standard error

27 Question 3 To what extent do you feel confident or unconfident that if you had a serious or life threatening illness you would be able to receive the best treatment for your condition in...? NET: Confident % 76% 75% 73% 51% 72% Very confident (4) % 26% 22% 19% 1 2% Fairly confident (3) % 49% 53% 53% 41% 18% 52% Not very confident (2) % 15% 18% 22% 34% 58% 21% Not at all confident (1) % 5% 4% 3% 13% 17% 4% NET: Not confident % 22% 25% 47% 75% 25% Don't know % 5% 3% 2% 2% 4% 2% Mean Standard deviation Standard error Question 4 Which statement most accurately reflects your view of health spending in...? We spend too much on health % 5% 14% 16% 22% 48% 8% The amount we spend on health is about right % 24% 41% 41% 25% 14% 31% We spend too little on health % 62% 39% 34% 46% 29% 53% Don't know % 9% 7% 9% 7% 9% 9% 26

28 Question 5 To what extent do you agree or disagree with each of the following statements regarding access to medicines? The people of Europe should have equal access to effective medicines, irrespective of where they live NET: Agree % 62% 85% 85% 91% 92% 88% Strongly agree (+2) % 36% 41% 47% 63% 62% 58% Slightly agree (+1) % 27% 45% 38% 28% 3 3 Neither agree nor (0) disagree % 11% 1 7% 5% 7% Slightly disagree (-1) % 6% 1% 3% 1% 1% 3% Strongly disagree (-2) % 7% 1% 1% * 1% 1% NET: Disagree % 13% 2% 4% 2% 2% 4% Don't know % 7% 1% 1% 1% 1% 1% Mean Standard deviation Standard error Countries should work together to get a better deal on the cost of medicines NET: Agree % 8 83% 85% 91% 9 93% Strongly agree (+2) % 49% 39% 43% 65% 52% 67% Slightly agree (+1) % 3 44% 41% 26% 39% 26% Neither agree nor (0) disagree % 14% 12% 1 7% 6% 5% Slightly disagree (-1) % 1% 2% 2% 1% 1% 1% Strongly disagree (-2) % 1% 1% 1% * 1% * NET: Disagree % 1% 3% 2% 1% 2% 1% Don't know % 5% 2% 3% * 2% * Mean Standard deviation Standard error

29 Assessments of the effectiveness of medicines should be made at a European level to reduce red tape NET: Agree % 68% 68% 79% 73% 88% Strongly agree (+2) % 19% 24% 27% 41% 37% 51% Slightly agree (+1) % 25% 44% 41% 38% 36% 37% Neither agree nor (0) disagree % 21% 17% 13% 15% 9% Slightly disagree (-1) % 9% 5% 6% 4% 4% 1% Strongly disagree (-2) % 11% 2% 3% 2% 3% * NET: Disagree % 7% 9% 6% 7% 2% Don't know % 15% 4% 6% 2% 5% 2% Mean Standard deviation Standard error Decisions on access to treatments should be decided by national governments and not at a European level NET: Agree % 67% 53% % 53% Strongly agree (+2) % 43% 19% 21% 21% 25% Slightly agree (+1) % 24% 34% 29% 29% 29% 28% Neither agree nor (0) disagree % 17% 27% 26% 25% 22% 27% Slightly disagree (-1) % 5% 9% 11% 15% 15% 11% Strongly disagree (-2) % 1% 4% 5% 8% 9% 5% NET: Disagree % 6% 13% 16% 22% 23% 16% Don't know % 1 7% 8% 3% 6% 3% Mean Standard deviation Standard error

30 Question 6 In your opinion, which of the following conditions is the most urgent health problem facing your country today? Cancer % 34% 61% 42% 59% 52% 61% Obesity % 27% 6% 14% 7% 11% 8% Heart disease % 11% 8% 1 17% 8% Mental illness % 11% 3% 18% 4% 3% 5% Diabetes % 7% 2% 5% 5% 8% 3% Dementia % 11% 2% 7% 4% 1% 3% Smoking % 2% 5% 3% 4% 6% 5% HIV/AIDS % * 4% 1% 2% * 1% Liver disease % * 1% * 1% * 1% Arthritis % 1% * * 1% * 1% Other % 2% 3% 2% 3% 2% 3% 29

31 Question 7 Which of the following do you think is the biggest challenge facing healthcare services today in your country? Shortage of funding % 23% 15% 12% 21% 15% 24% Staffing shortages % 13% 32% 31% 7% 4% 16% Waiting times for treatment % 11% 7% 9% 26% 28% 19% Too much bureaucracy % 18% 14% 21% 15% 16% 11% Late diagnosis of life threatening illness % 8% 1 11% 1 21% 15% Quality and safety of healthcare % 3% 3% 7% 14% 6% 7% Pressures on accident and emergency services % 13% 8% 3% 2% * 2% Poor access to effective medicines % 3% 5% 3% 3% 6% 4% Poor access to GPs % 5% 4% 1% 1% 3% 1% Other % 3% 3% 2% 2% 1% 2% 30

32 Question 8 If you had a serious or life threatening illness, how likely or unlikely would you be to travel to another country for specialist hospital treatment? Unweighted base Weighted base NET: Likely % 19% 13% 23% 36% 27% 15% Very likely (4) % 5% 3% 7% 9% 6% 3% Fairly likely (3) % 14% 1 16% 27% 11% Not very likely (2) % 39% 38% 41% 45% 42% Not at all likely (1) % 33% 38% 3 12% 13% 33% NET: Not likely % 66% 77% 68% 53% 58% 75% Don't know % 15% 1 8% 11% 15% 11% Mean Standard deviation Standard error Question 9 To what extent do you agree or disagree with the following statement: Health authorities need to do all they can to cure diseases and this includes cutting red tape on the use of my personal health information to help research? NET: Agree % 7 64% 76% 78% 85% 85% Strongly agree (+2) % 34% 43% 48% 58% Slightly agree (+1) % 34% 45% 41% 35% 37% 27% Neither agree nor (0) disagree % 16% 22% 15% 13% 9% 9% Slightly disagree (-1) % 4% 5% 3% 4% 2% 4% Strongly disagree (-2) % 3% 2% 1% 1% 1% 1% NET: Disagree % 7% 7% 4% 5% 2% 5% Don't know % 8% 7% 5% 3% 4% 1% Mean Standard deviation Standard error