Health care for older adults

What the Commonwealth Fund 2024 Survey tells us about the state of health care services in the UK

Most high-income countries have ageing populations. In 2024, there were 33 people aged 65 and older for every 100 people of working age (20–64-year-olds) on average across the OECD. This is expected to rise to 55 people aged 65 and older for every 100 working-age people by 2054. 

Although many older people are in good health, we are all more likely to develop ill health as we age. In 2021/22, 40% of people aged 65 and older in the EU reported having at least two chronic conditions. A central challenge for many countries is to enable older people to stay healthy for as long possible – partly to minimise rising demand on health systems. Healthy ageing depends on much more than good health care: adequate housing, and transport to enable access to leisure and physical activity, for example, are vital. But it is also important that health care services are geared towards diagnosing diseases early, managing multiple conditions and being accessible to older age groups. 

The UK is no exception to these population trends. By 2040 the number of people living with major illness in England will increase by over a third (from 2019 levels), and most of this increase will be among people aged 70 or older. The new 10-Year Health Plan flags the ageing population ‘living with multiple health conditions’ as a primary challenge. The plan sets out reforms to boost primary and community care and significantly extend the use of digital technology to improve the quality and coordination of care for people with multiple conditions. But previous attempts to boost community-based care have struggled and the share of resources that flows to hospitals has continued to grow.

The NHS is in a fragile state. Waiting times targets for hospital care have not been met for over a decade. Public satisfaction with general practice has plummeted, with difficulties getting an appointment a major concern. The percentage of patients with chronic conditions who say they get enough support with their conditions has fallen, from 43% in 2018 to 28% in 2023. Older people generally report higher satisfaction with services than younger age groups do, but are more likely to have longer waits for emergency care. More older people are also waiting for planned hospital care.

About this briefing 

Comparisons of older people’s experiences of health care services across countries can provide useful context for understanding how well the NHS is responding to people’s needs as they age, and where improvements might be possible. The Health Foundation collaborated with the Commonwealth Fund to survey older adults (people aged 65 and older) in 10 high-income countries about their experiences using a range of services, including primary care, hospital care and specialist care. The survey, conducted in 2024, is part of the International Health Policy (IHP) survey series, which has been running for more than two decades, covering primary care doctors, all adults and older adults. Previous surveys of older adults took place in 2021, 2017 and 2014. 

This piece analyses the results of the 2024 survey, comparing responses from the UK with those from other countries. We present findings on a range of experiences with health care, including general practice, out-of-hours and remote care, hospital care, the cost of accessing services and end-of-life care planning. In the final section, we draw out some themes for policymakers, with a focus on England. 

Overall experiences of care 

The survey began by asking people about their views on the overall quality of health care they had received over the past 12 months. Alongside Sweden and Canada, older people in the UK were least likely to be ‘very’ or ‘somewhat’ satisfied with their care. Two-thirds (66%) of people in the UK said they were ‘very’ or ‘somewhat’ satisfied with the quality of their care, with Sweden (66%) and Canada (67%) reporting similar levels of satisfaction. All other countries reported significantly higher satisfaction levels (Figure 1). 

General practice and out-of-hours care

Access

People were asked how quickly they could see a doctor or a nurse the last time they were ill (not including visits to emergency departments). For most countries, including the UK, this meant seeing a doctor or nurse at a GP surgery. Results are set out in the three charts in Figure 2.

45% of UK respondents said they were able to get an appointment (in person or virtual) on the same or next day, with only the Netherlands reporting a higher proportion of same or next day appointments (61%). However, these results for the UK represent a decline of almost a third in the UK since 2014 (when it was 60%), following a similar trend across surveyed nations.

In contrast, the UK performs less well compared with other countries on timely communication with a primary care provider. Among people with a regular doctor or practice, 36% of UK respondents said they ‘always’ received an answer on the same day while trying to contact their practice about a medical concern, with only Sweden reporting significantly lower proportions. In the UK, this has fallen by 38% since 2014, following similar declines in all other countries.

The survey asked about people’s experiences of getting medical care in the evenings, weekends and public holidays without going to A&E. Of those people who reported needing out-of-hours care, only 12% of UK respondents said it was ‘very easy’ (significantly different from the Netherlands, Germany and the US, who were the best performers). This compares with 35% reporting it was ‘very easy’ in 2014. 36% of UK respondents, meanwhile, said it was ‘very difficult’ to get access to out-of-hours medical care, with only Canada (43%) and Sweden (47%) reporting higher proportions.

Older adults in the UK with mental health problems and chronic illnesses were significantly more likely to need care out of hours and to find it ‘somewhat’ or ‘very’ difficult to access such care. 

Using remote care 

More people in the UK (38%) reported receiving remote care (by video or telephone instead of in person) from their primary care provider in the last 12 months than most other surveyed countries. As shown in Figure 3, this represents a significant difference with every country except Australia (34%). Within the UK, older people with mental health problems and chronic illnesses were more likely to receive remote care than those without.

Among those who had remote appointments in the UK, the vast majority (93%) agreed that they were ‘always’ or ‘often’ treated with courtesy and respect. This was similar across surveyed countries, Australia being the only country with a significantly higher proportion (98%). 

At the same time, only 72% of people in the UK were ‘very’ or ‘somewhat’ satisfied with the overall care delivered remotely, compared with 82% average across surveyed countries. 

Digital communications

24% of respondents in the UK (with a regular doctor or practice, not just those who had had virtual appointments) said they had used a secure website, patient portal or app to communicate with their provider about a medical question or concern over the last 2 years. As shown in Figure 4, this puts the UK above the Netherlands (19%), Canada (11%), Switzerland (11%), Australia (9%), Germany (8%) and France (6%). 

However, the UK was just below average for people reporting that they had received digital communications from health care providers (24%). 20% had viewed patient summaries online (average of 24%) and 26% had viewed test results online (average of 31%).

Continuity of care and care coordination

The survey asks people whether they have a regular GP practice that they go to. In the UK, 98% of people said they did, similar to the average across countries. However, the UK ranks lower than most other countries for people reporting that they have a regular doctor/GP they usually go to for their medical care. 72% said yes, one of the lowest proportions compared with other countries. This is also a significant drop in the UK from the 2014 survey, when 92% said they had a regular doctor (Figure 5).

The survey asked people how many doctors (of all kinds, not just GPs) they had seen in the past 12 months. People in the UK had seen two different doctors on average, similar to the average of other surveyed nations. 16% saw four or more doctors over the same period and people with mental health problems, chronic illnesses and/or who are severely limited in everyday activities were significantly more likely to see four or more doctors. 

People who said they had seen more than one doctor in the past 12 months were then asked how often their regular GP or someone in their GP practice helps coordinate or arrange the care ‘from other doctors or places’. Fewer than half (47%) of UK respondents said they ‘always’ or ‘often’ received help from their primary care practice in the UK (Figure 6), down from 65% in 2021. This placed the UK below average (52%), with those in Australia (72%), Switzerland (62%), New Zealand (62%), Canada (61%) and the US (58%) reporting more support. All countries have seen a downwards trend on this indicator since 2017.

The survey asked people if they thought there were coordination issues with information transfer (when either the doctor/practice or specialist/consultant did not have up-to-date information from the other). 26% of UK respondents reported instances of this, above Australia, Canada, Netherlands and Switzerland (all between 17% and 19%). This has increased significantly in the last 3 years in the UK, with an average of 16% across 2014, 2017 and 2021 surveys. Information flow was a more frequent problem for people with mental health problems (35%) and people severely limited in everyday activities (34%).

Hospital and specialist care

People in the UK were comparatively less likely to have seen a specialist in the last 2 years than all other surveyed nations, except New Zealand. 54% of people said they had seen a specialist in the UK compared with 84% in Germany – the highest rate. People in the UK reported fewer hospitalisations than the other countries too. 21% reported that they had been admitted into a hospital for at least one night in the past 2 years, lower than the average of 28% (no country reported a significantly lower percentage).

Figure 7 shows that UK respondents reported above average experiences of being discharged from hospital compared with other countries. Among participants reporting an overnight hospital stay in the past 2 years, they were more likely to have their prescriptions reviewed before discharge (76% against an average of 69%), which is an increase on the 2021 older adults survey (66%). Only the US reported a significantly higher result (83%).

People in the UK were also more likely than the average to report having support from the hospital after discharge. 77% received support to arrange follow-up care, 77% received written information for self-care and 82% had the support and services needed to help manage their condition at home. For all three questions, only the US had statistically higher results (84%, 93%, 91%).

31% of UK respondents said they had used A&E at least once in the past 2 years, a similar rate to other countries. Of those who had attended the emergency department at least once in the past 2 years, about a fifth (19%) attended for a condition that they thought could have instead been treated by their regular GP or GP practice (only France reported a lower figure, of 7%).

Cost barriers 

The UK continues to be among the best ranked countries for people reporting that cost barriers to access care are low. In total, only 12% of respondents said they faced a cost barrier of some kind. This meant people avoided collecting a prescription, skipped doses of medicine, avoided consulting with a doctor, skipped a medical treatment or follow up, did not visit a dentist or did not get mental health services due to the cost.

As Figure 8 shows, reported UK cost barriers are therefore significantly lower than in Australia, Canada, New Zealand, Sweden, Switzerland and the US (between 17% and 30%). Dentistry is one of the main health care expenses in the UK. 9% reported dentistry cost barriers (which is still below the average of 13% for all nations surveyed). Across these questions, older people with mental health problems or severely limited in everyday activities were more likely to report cost barriers.

The survey asked people how much they spent on ‘out-of-pocket care’ – the cost of any medical treatments and services not covered by their insurance system or national health service. This included prescription drugs, medical and dental care, and any associated co-payments. In the UK, people spent less than in the other countries surveyed. 57% spent under $100 on their health care in the past 12 months, while all other countries had significantly fewer people reporting spending under this amount (Figure 9).

Despite being one of the best performers, people in the UK are reporting higher levels of spending than in the past. The proportion of older adults in the UK spending $1,000 or more has doubled to 12% since 2021. Those with mental health problems reported significantly more costs. In addition, 12% of respondents said they are covered by private health insurance that they (or family) pay for, or an employer provides, with younger respondents (65 to 74-year-olds) significantly more likely to have insurance than those aged 75 years or older.

Chronic health conditions

All chronic conditions 

Older adults were asked if they had been diagnosed with a chronic condition. This included hypertension, heart disease, diabetes, asthma or chronic lung disease, depression, anxiety or other mental health conditions, cancer, joint pain or arthritis, a stroke, neurological problems and chronic kidney disease or kidney failure.

Fewer people had been diagnosed with a chronic condition in the UK (81%) than in other countries – only the Netherlands (70%) and Switzerland (77%) reported lower rates. However, when it came to receiving support for such conditions, the UK ranked consistently low on all metrics. 63% of older adults were seeing a health care professional for their condition, above only the Netherlands (48%) and Switzerland (59%).

The UK was among the lowest ranked countries for health care professionals discussing main goals and priorities in caring for chronic conditions, and for giving clear instructions on symptoms to watch for and when to seek further care (Figure 10).

The UK measured close to the average for the number of different medications older adults were prescribed, with a mean of 3.6. Of people taking at least two prescription medications on a regular basis, 69% said that a health care professional had reviewed these in the past 12 months. This was much lower than the best performing countries – the US (91%), New Zealand (79%) and Canada (75%) – but close to the average (69%).

Mental health

Older adults were specifically asked about their experiences of mental health. In the UK, fewer people reported diagnoses of mental health conditions than in most countries. 15% of UK respondents said they had experienced emotional distress in the past 12 months (less than the average of 18%), and 4% said they received counselling or treatment for their mental health (no countries were significantly lower). Across these questions, UK respondents with lower income, chronic illness or severely limited in everyday activities were more likely to report mental health problems.

End-of-life wishes

Fewer than half (47%) of older adults in the UK reported that they have had a discussion with family, friends or a health care professional about their treatment preferences if they could not make decisions for themselves due to illness. While this has increased from 38% in 2014, only France (38%) and Sweden (31%) reported lower percentages on this question in 2024 (Figure 11). In particular in the UK, women (52%) were more likely to have had this conversation than men (41%).

Similarly, a low percentage of people (20%) said they had a written plan describing the health care treatment they want (or do not want) at the end of their life – lower than the 10-country average of 34%. Australia, Canada, Germany, the Netherlands, New Zealand, Switzerland and the US had significantly higher results for both questions.

The survey paints a mixed picture of the quality of health care in the UK. There are some clear strengths, such as the UK’s lower cost barriers to access care. But in some key areas, for example people’s ability to see the same GP, there have been declines in the UK compared with some other countries. In this section we draw out some of the policy implications in England, which may also be relevant to policymakers in the devolved nations.

General practice

General practice is the cornerstone of health systems and is fundamental to caring for  people effectively as they age and develop chronic conditions. In England, general practice has been under increasing pressure for several years, as numbers of full-time permanent GPs has fallen at the same time as the population has grown.

While shortages of GPs are not unique to the UK, the pressures on general practice in England have led to steep falls in public satisfaction, including among older age groups. Since 1997, successive governments have prioritised policies to make access to general practice easier. Since 2019, there has been a significant expansion of non-GP ‘direct patient care’ staff (including clinical roles such as pharmacists), which has helped increase the number of appointments in general practice.

The survey suggests that in terms of GP appointment timeliness (consultations on the same or next day), performance in the UK is good compared with most other countries surveyed. This is broadly consistent with GP appointments data for England, which recorded just under 44% of appointments having taken place on the same day in March 2024 (and just over 44% in April 2025).

This is offset by a relatively poorer performance on ‘getting an answer the same day’ to a medical question or concern, where a third of older people in the UK said they always got a response on the same day, compared with over half in the Netherlands and Germany. Not all contacts might need a same-day response, but improving the responsiveness of general practice has been a policy goal for successive governments. In 2023, the government invested £240m in a programme to improve telephone and online contact with general practice, so that patients ‘will know on the day they make contact how their query will be managed’. This policy has been continued by the Labour government.

The annual GP patient survey, which captured the experience of nearly 700,000 patients in 2024, paints a different picture to the international survey. In those results, 88% of people said they knew what the next step would be after contacting their practice, either immediately or by the end of the same day. But the GP patient survey also shows that many people struggle to contact their practice: 38% said it was ‘difficult’ to contact their practice by phone, and more than 70% of people who had used the phone to contact the GP reported waiting in a queue for an answer. 

Continuity of care

Speed of access to appointments is only one dimension of good access in general practice. Patients value the option of seeing the same clinician, and continuity – the long-term relationship between a patient and provider – is a core function of general practice. The survey shows that a bigger gap has opened up over time between the UK and other countries in people reporting having a regular doctor they see for their medical care. It also shows a 20 percentage point drop over time in the UK, from 92% in 2014 to 72% in 2024. 

The ability to see the same primary care doctor is associated with lower mortality, lower avoidable emergency hospital admissions and higher patient satisfaction. In opposition, Labour promised to improve continuity of care for patients who would benefit most, including those with chronic conditions. Since the new government took office in July 2024, the manifesto promise to ‘bring back the family doctor’ remains a policy goal. Measuring continuity of care is complex and will take time to implement. The latest GP contract has included financial incentives for primary care networks (groups of general practices) to stratify their patients to identify those who would most benefit from continuity of care.

Policymakers need to find the right balance between speed of access and more continuity of care. Improving continuity of care in general practice will need sustained effort to increase both the number of GPs and the number of hours they work in the same general practice. An investigation by the Health Services Safety Investigations Body in 2023 found that some GP practices said they were unable to offer continuity of care because of GP shortages and reliance on part-time or locum staff, particularly in deprived areas or rural areas. Some GP practices have managed to deliver more continuity for patients, despite the challenging conditions in general practice, provided there is adequate support to redesign services.

Other signals of pressure on UK general practice relative to other countries include below- average proportions of people saying the practice helped coordinate or arrange care for them (29% of UK respondents said this ‘always’ happened, compared with 59% in Australia). There were lower proportions of patients with chronic conditions in the UK reporting having discussed goals or being given information on signs and symptoms to look out for.

GPs have reported that managing referrals has become more complex and time consuming (not helped by limited digital integration between hospitals and general practice), while other administrative tasks have grown in volume. In 2024, the government launched a ‘red tape challenge’ to reduce the burden of administration on GPs, which has yet to report its findings. The 10-year plan sets out a future in which AI and the successful rollout of a single patient record will relieve some of the administrative burden on GPs, but timescales are not yet clear. 

Digital and remote access

In the 10-year plan, the government promised ‘to create the ‘most digitally accessible health system in the world’. This envisages a significant expansion of both the use of the NHS app and its functions, including providing medical advice, expanding remote consultations, booking appointments and offering tools to manage chronic conditions. The 2024 older adults survey suggests that in terms of virtual appointments with GPs or other primary care staff, the UK already makes more use of these compared with other countries. At the same time, older people in the UK report more limited use of other forms of digital interaction with general practice, for example viewing test results or patient summaries. 

Surveys of digital capability suggest that although there have been improvements, age is still associated with lower digital use and skills: in 2024, 13% of 60–69 year olds had not been on the internet in the past 3 months. The government has identified older people as one of the groups at risk of ‘digital exclusion’, lacking the skills or resources to use digital technology. In the 10-year plan, the government has promised to develop the NHS app inclusively, involving patients in its design and testing, but patient groups have previously called for the retention of non-digital methods to access care alongside digital.

Health Foundation polling has found that compared with younger age groups, more older people felt that being able to see and talk to NHS staff was the most important consideration when using health technologies. Nevertheless, another poll found that people aged 65 and older were more likely to agree that making better use of digital technology should be a top priority for the NHS than younger cohorts. The evolution of a more digitally enabled NHS will likely require careful monitoring to ensure that certain patient groups are not left behind, especially those older people with chronic conditions who use health services the most.

Out-of-hours care

The survey also finds that many older people struggle to access care out of hours, at weekends, evenings or on public holidays. Although reported use of A&E by UK respondents was not higher than other countries as a result, it does signal that improvements are needed. The survey does not explore why people had found it difficult, but the Care Quality Commission’s 2024 State of Care report found that the responsiveness of NHS 111 to calls from patients – the main route to local out-of-hours services and advice – was ‘consistently poor.’ The government’s urgent and emergency care plan is focused on improving the worst ambulance and A&E delays, but it is not clear how quickly the 10-year plan’s promises of more appointments in general practice and a better NHS app will improve the experiences of people needing care out of hours.

Cost barriers

Similar to previous surveys (of older adults and all adults), people in the UK reported some of the lowest cost barriers to care. Nevertheless, two findings are of interest.

First, 9% of older adults reported having skipped dental care because of the cost. In England, older adults are not exempt from NHS dental care charges, unless they are on low incomes. Shortages of NHS dentists have been a longstanding problem, and many of those unable to access an NHS dentist may struggle to afford a private dentist. Despite higher levels of need due to increased prevalence of oral diseases among older age groups, cost is a barrier to dentistry. Reforms by the previous Conservative government in 2024, designed to increase the number of dentists and courses of NHS treatment, have been judged a failure. The 10-year plan has promised a ‘transformed’ NHS dental service by 2035, with an improved dental contract and an initial focus on children’s dental care.

Second, there has been an increase in the proportion of people saying they had spent more than the equivalent of $1,000 on medical treatments or services not covered by the NHS or private health insurance. While still low compared with other countries (12% in the UK), the rise of 6 percentage points since 2014 is concerning. The survey does not provide any detail on what services this spending might have been on. There is some evidence that more people opted to pay ‘out of pocket’ for non-urgent hospital procedures as NHS waiting lists have grown, especially for procedures such as hip replacements. But the Office for National Statistics has also recorded increases in out-of-pocket spending on dental care, which was nearly 11% higher in 2023 than before the pandemic in 2019.

Care planning and end-of-life care

The survey suggests there is room for improvement to enable more people to plan for how they might want their care to be delivered in the event of serious illness and loss of capacity, as well as at the end of life. The NHS recommends that people with terminal illness or who are approaching the end of their life create an ‘advance care plan’. These may take various forms and are not legally binding. Examples include the Recommended Summary Plan for Emergency Care and Treatment, designed to avoid invasive emergency care, such as resuscitation, against a patient’s wishes.

Evidence suggests that take up of these plans is still limited: a 2018 audit of emergency admissions in England found that only 4.8% of patients had an advance care plan, though the likelihood increased with age (more than 12% of patients aged 90 or older had a plan). A UK-wide survey of adults (published in 2024) found that while more than 80% of people felt comfortable having a conversation with family and friends about plans for death and dying, only 14% reported having made plans about future care preferences relating to serious illness and dying. 

While the passage of the Assisted Dying Bill through parliament has raised awareness of the debate about end-of-life care, there is still considerable uncertainty about its future impact on existing end-of-life services in hospital and the community, which are under considerable strain.

The Darzi review flagged that end-of-life care needed to improve, to better meet people’s preferences and avoid unnecessary emergency admissions. The 10-year plan has limited detail on how it proposes to improve end-of-life care, beyond a commitment to provide ‘more community-based advice and support to die at home’. Other promises to provide a care plan to 95% of patients with complex care needs by 2027 could include end-of-life preferences, and a successful rollout of a single patient record would also benefit this group. 

Although there are limits to what we can learn from surveys of this kind, the findings do offer some pointers for policy about where the NHS could improve, mostly in out-of-hospital care. While the survey suggests that experiences of hospital care were above average for the UK (on support with medications and follow-up after a hospital stay), the survey did not ask about hospital waiting times for routine care, where the NHS was a clear outlier compared with other countries in last year’s survey of all adults. Nor did it ask about experiences of using emergency hospital care, where evidence suggests that older people bear the brunt of 12-hour ‘trolley’ waits for admission. Faster access to routine and emergency care in hospitals needs to remain a priority for the NHS. 

But the results reinforce known weaknesses in primary care, and highlight that more needs to be done to ensure that general practice in particular can offer better continuity of care for older people, and provide services that are well coordinated, accessible and responsive.

The 10-Year Health Plan sets out a vision of stronger, better coordinated primary and community care: making this happen will be essential to improve care for older people. It will also be vital that the digitally enabled future set out in the plan is developed so that it meets the needs of older people, particularly those with highest needs who are most at risk of being excluded from services.