Feeling the pressure: what the 2023 Commonwealth Fund survey reveals about the state of the UK health system

The challenges facing the NHS across the UK are formidable. In England, waiting-time targets for routine and emergency hospital care have not been met since 2016, and the waiting list remains over 7 million. Waiting times are measured differently across the UK, but have also risen in Scotland, Wales and Northern Ireland, particularly since the pandemic. At the same time, pressure on general practice has been intense across the UK, driven by rising demand and shortages of GPs. In England, general practice appointments have increased since 2019 while the number of full-time equivalent, fully qualified GPs has fallen. 

These pressures are mirrored in the views of patients and the public. In 2023, more patients in England reported difficulties contacting their GP practice than ever before. Patients’ experiences of inpatient hospital care, particularly waiting times and staffing levels, have also deteriorated since 2020. In the 2023 British Social Attitudes Survey, people in England, Scotland and Wales reported the lowest levels of overall satisfaction with how the NHS is being run since the survey began in 1983, with record low levels of satisfaction with GP services and dentistry.

The NHS was a dominant theme in the 2024 general election, with improvements promised in the manifestos of the three main political parties. The NHS was declared ‘broken’ by the incoming Secretary of State for Health and Social Care, who has promised to diagnose the problems and fix the NHS.

The causes of the pressures facing the NHS are complex. In England, average funding growth between 2019/20 and 2024/25 has been below the long-term average (3% compared with 3.8% between 1979/80 and 2019/2020). For the UK as a whole, investment has lagged behind comparable European countries since 2010. But other sources of pressure, for example the impact of the COVID-19 pandemic, staff shortages and the growing demand for health care as populations age and develop more chronic conditions, are also being experienced by health systems in Europe and elsewhere.

To provide some context for the severity of the pressures on the UK’s health service compared with those in other countries, this analysis presents the findings of the 2023 International Health Policy Survey of adults in 10 countries on their experiences using health care services. The Health Foundation collaborated with the Commonwealth Fund on the International Health Policy Survey, which has been running for nearly 2 decades and includes surveys of GPs and older adults. 

For the 2023 survey, adults aged 18 and over in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the US and the UK were asked about their experiences using a range of services, including primary care, hospital care and specialist care. Questions explored a range of issues such as access, use of digital technology, doctor-patient interactions, coordination and affordability. 

Previous International Health Policy Surveys of all adults took place in 2013, 2016 and 2020 and were used to analyse time trends. 

Respondents for the 2023 survey were selected, using a random sampling approach, to be representative of adults in each country. The final sample comprised of 21,341 respondents across all 10 nations, of whom 3,361 were living in the UK. Interviews were conducted via telephone or online, with roughly half of UK interviews conducted online. Response rates by country varied from 5.8% in the UK to 48.8% in Switzerland. All fieldwork was completed between March and August 2023. Data were weighted to reflect country-specific demographic distributions of adults and to account for probabilities of selection and sample design. Country-specific wording was used in the questionnaire where appropriate. 

In this analysis, we highlight statistically significant differences between the countries at 95% confidence. We do not report non-statistically significant differences (for instance, when results in the UK are not significantly higher or lower than another country). Where stated, averages are calculated as the mean percentage across all 10 countries' responses in the International Health Policy Survey. Finally, percentages are rounded to the nearest whole number, and percentages relating to very small numbers of respondents are excluded, resulting in some bar charts summing to marginally greater or less than 100%. Further information on the survey methods can be found in the 2023 International Health Policy Survey methodology report. Information on the methods used in the previous surveys of all adults cited in this report also can be found online.  

Our findings have some limitations. First, answers to the survey questions were self-reported and could have been influenced by factors beyond a person’s own experiences, for example news coverage. Such factors are likely to differ among countries, so it is important that conclusions are interpreted cautiously within the broader policy context of each health system. 

Second, the survey reflects a snapshot in time. It is not possible to know the chronology of any reported participant experience or draw causality from the associations reported. While the survey does not follow the same individuals over time, notable changes to answers compared with previous International Health Policy Surveys have been reported where available.

Third, a common limitation of all voluntary surveys is that not everybody responds. If the people who do not respond have different views on key questions than those who do, it can affect the results. While the weighting approach attempts to adjust for this non-response using known population characteristics, the lack of responses and small sample sizes make it hard to draw conclusions about the experiences of some population groups.

General practice 

Getting an appointment

97% of people in the UK reported having access to a regular GP or GP practice, with other countries ranging from 99% in the Netherlands (the highest) to 86% in Canada (the lowest). People were asked how quickly they were able to get an appointment with a GP or nurse the last time they needed it. Of those who needed to make an appointment, around 2 in 5 people in the UK (42%) were seen on the same day or the next day (Figure 1, slide 1). This places the UK among the better-performing nations with respect to same- or next-day appointments, with only the Netherlands (50%) and Germany (49%) significantly higher. 

The results of the 2023 survey confirm many of the known challenges facing the NHS across the UK, especially pressure on general practice and hospital services. They also flag that some of these pressures are not unique, also existing in other health systems. The UK’s results suggest some areas of strength compared with other countries. In this section, we draw out some of the implications of the survey, primarily for England, but also for the UK where data permit.

General practice

On the more positive side, the UK still ranks highly in the proportion of people who report having a regular GP practice (97%). Having a regular GP practice is considered a fundamental building block of primary care: in countries with low or falling percentages of people with a regular GP practice, for example the US or Canada, experts worry that the health system will struggle to effectively prevent, diagnose and treat disease early, or manage chronic disease, as a result. 

The UK also performs well compared with many countries on the proportion of people reporting that they can get an appointment on the same or next day (42%). For England, this is broadly consistent with other sources of evidence, including GP activity data (which show that 52% of GP appointments happen on the same day or day after someone contacts the practice) and the 2023 GP Patient Survey (which found that 44% of patients were seen on the same or next day after trying to book an appointment). 

Other responses underline the severity of the pressures on general practice. The UK stands out for difficulties getting a same-day answer for a medical problem. While not all queries need a same-day response, the results of this survey are similar to those of the 2023 GP Patient Survey for England, suggesting increasing problems for patients in making contact with their practice. For the first time since 2012, more patients said it was difficult to get through to their practice on the phone than said it was easy (and over 80% of patients still use the phone to book appointments). Difficulties contacting a GP practice were also reflected in the most recent national surveys in Scotland and Wales.

The survey findings suggest that the pressures on general practice are also being felt once patients get an appointment. The UK tended to score poorly compared with other countries on questions about one’s GP spending sufficient time with them, explaining things in ways that are easy to understand and involving them in decisions about care and treatment. 

The backdrop to these results is well known. In England, the volume of GP appointments needed is at record levels but the number of full-time, fully qualified GPs has fallen since 2015, as has the proportion of overall NHS funding going to primary care. Recent government policy has prioritised making it easier for people to contact their practice (for example through better telephone systems) and increasing the number of available appointments, particularly through increasing non-GP staff. But there are concerns that these policies – primarily aimed at increasing the ‘supply’ of appointments – may be at the expense of other important dimensions of general practice, for example the importance of continuity of care, which is linked to better outcomes and may be more efficient in the long run.

As with our 2022 survey of GPs, this latest survey found there are significantly more general practice appointments taking place by phone (or video) in the UK than in many other countries. In England, the pandemic led to a rapid switch to virtual GP appointments, and the proportion of GP appointments that were face-to-face fell to 36% at its lowest in April 2020. In 2021, the government urged GP practices to increase face-to-face appointments. The proportion of face-to-face appointments has increased relative to virtual appointments but remains below pre-pandemic levels. Although GP practices are still criticised in the media for over-reliance on virtual appointments, this survey suggests that most people (75%) were satisfied with virtual consultations, similar to other studies. The OECD has noted significant variations in the degree to which countries switched to remote consultations during and after the pandemic and has encouraged systematic collection of data on their value and accessibility to people from all demographic groups. 

Improving access and quality in general practice is a priority for governments across the UK, but other countries also face challenges in primary care. Many countries in Europe have shortages of general practitioners and are developing policies to increase the supply of GPs, especially in more rural and remote areas. The OECD has also identified weaknesses in primary care across nations – including poor coordination, inefficient use of staff skills and not enough focus on prevention – that need to be rectified as countries face the challenge of ageing populations with more chronic illness and rising health system costs. 

Hospital and specialist care 

The survey confirms known pressures on the UK hospital system. In England, monthly attendance at all types of A&E was 2.32 million in July 2024, 6% higher than in 2023, and all four countries of the UK have seen longer waits for emergency care since 2013. The causes of higher attendance at A&E are complex: difficulties accessing general practice are likely to be only one factor (others include seasonal illnesses, the residual impact of COVID-19 and growing levels of complex health conditions associated with an ageing population). In this survey, a third of people who used A&E thought their problem could have been treated by their regular doctor if they had been available, but the survey did not ask why the GP was unavailable, for example because it was out of hours. In England, the GP Patient Survey found that 12.2% of patients who got through to their GP but were either not offered an appointment or were unable to take the offered appointment attended A&E instead. In England, current policy aims to increase the capacity of urgent and emergency care outside hospitals, including NHS 111.

The UK also stands out for long waits for specialist care and elective procedures. This survey suggests that the proportion of people waiting more than 4 weeks to see a specialist has slowly risen in all countries since 2013, but the UK has gone from being one of the best performing countries to the worst (alongside Canada) for reported waits of over 1 year for a specialist or consultant appointment. 

Almost without exception, health systems across the world experienced disruptions to hospital services in 2020 and 2021 as a result of the pandemic. The OECD estimated that 2 million fewer elective surgeries took place in 23 European countries in 2020 than in 2019, with backlogs common. A 2022 analysis of European countries by the WHO found that some health systems had successfully reduced these backlogs, but noted that this was harder in places with low numbers of health care workers pre-COVID or less financial capacity to increase supply. 

The UK has spent less per head on health care over the past decade than many comparable countries with shorter waits, such as Germany. But Canada and Sweden also experience problems with long waiting times that precede the pandemic. Both spend more per capita on health care than the UK. In England, current policy to reduce waiting times for elective care includes many of the strategies used by other health systems: using target waiting times, increasing the supply of staff and financial incentives for providers. But historically low levels of investment in NHS buildings and equipment compared with other countries, combined with the lingering impact of COVID-19, likely contribute to the slow progress in reducing long waiting times in the UK. 

Financial protection

In previous comparisons of international performance by the Commonwealth Fund, based on the International Health Policy Survey and OECD data, ‘affordability’ of health care for patients is a key attribute of a high performing health system, and an area in which the UK has ranked highly over several years. Analysis of household survey data (from 2018 and 2019) by the WHO also finds that the UK has some of the lowest levels of ‘impoverishing’ or ‘catastrophic’ household spending on health care in Europe.

In this survey, although the UK still has smaller proportions of people reporting cost barriers to accessing doctors, tests or treatments than some other countries, these percentages have risen slightly in recent years and are of concern in a health system that is predominantly free at the point of use. In England, a series of Healthwatch surveys between October 2022 and March 2023 (a period of high inflation) found that 11% of people had avoided making a health care appointment because of the cost of a call or internet access, and a similar proportion had avoided attending appointments because of the cost of travel. These challenges are likely to have compounded the disadvantage faced by those on low incomes who live in deprived areas, where rates of ill health and the need for health care are higher and the number of GPs is likely to be lower.

In England, higher proportions of people reported not collecting medication or skipping doses because of the cost compared with respondents in Scotland, Wales and Northern Ireland, where prescription charges have been removed. Although a range of exemptions are in place in England, for example for people aged 60 years and older or people with certain health conditions, advocacy groups have argued for free prescriptions for all people with long-term conditions and say financial pressures are causing worse health among those who cannot afford their medication.

Compared with other medical services, UK respondents reported the highest proportion of cost-related barriers to dentistry, with many other countries experiencing similar problems. These problems are likely linked to both user charges for NHS dental treatment and a shrinking proportion of dental practices offering NHS treatment, a trend in all four countries of the UK. In the 2023 British Social Attitudes survey, more people reported being ‘very dissatisfied’ with NHS dentistry (28%) than any other NHS service. 

A lack of accessible and affordable dental care is not unique to the UK. A study of dental care in European countries found that on average more than half of dental care spending is out of pocket, and dental care is the most common type of care people go without for financial reasons. Countries with more comprehensive public insurance cover (for example Germany) or with affordable voluntary health insurance (the Netherlands) have lower unmet needs for dental care. 

This survey reveals the extent of pressures on the NHS. On many indicators, the UK ranks among the lower performers, especially in relation to waiting times for hospital services and some aspects of primary care. While no health system consistently outperformed others in this survey, many of the countries where people reported shorter waiting times and easier access to services have higher levels of spending, though higher spending does not deliver better performance in all cases.

In England, the new government has been blunt about the poor state of health services. It has pledged to investigate the causes before setting out its plans to remedy them. Alongside reforms to improve responsiveness and productivity, any long-term solution will also need sustained, additional investment in services and capital if the NHS is to regain ground compared with other health systems. 

About the Commonwealth Fund’s 2023 International Health Policy Survey of the General Population in 10 Countries

The Commonwealth Fund provided core funding, with co-funding or technical assistance from the following organisations: the Canadian Institute for Health Information; Commissaire à la santé et au bien-être du Québec; Ministère de la Santé et des Services sociaux; Ontario Health; La Haute Autorité de Santé; German Ministry of Health and the Robert Koch Institute; Stichting Radboud universitair medisch centrum (Radboud University Medical Center); the Swedish Agency for Health and Care Services Analysis (Vård- och omsorgsanalys); the Swiss Federal Office of Public Health; and The Health Foundation.