When we went to talk to British ex-pats who’d retired to Spain, it was not surprising to find them enjoying the ‘good life’. Sun, sea and the ready community of other British retirees all made Mallorca or the Costa Blanca a more attractive retirement prospect than the damp houses, heating bills and social isolation they’d left behind. What was more surprising in our study was their wholehearted faith in the Spanish health care system. Typically people prefer familiar surroundings when ill – so why did ex-pat pensioners trust local hospitals and doctors more than the NHS? One reason was their high exposure to negative stories about the NHS in English language media, yet few recent personal encounters with the NHS. This raises crucial questions about what fosters trust in health care provision.
This preference for Spanish health care over returning to the UK for treatment was rather unexpected. We had assumed that, as the pensioners got older and needed more health care, they would face problems. Few had learnt enough Spanish to sustain communication with a doctor; few had much understanding of how the Spanish health system worked; few had much faith in what they called the ‘mañana’ culture of the Spanish public sector in general.
However, they overwhelmingly reported high trust in the Spanish health service:
“I go to the new hospital … it’s the best hospital in Europe … it’s beautiful, it’s clean, it’s airy, it plays music in the corridors. Can’t fault the medical care out here, the attention you get is marvellous, it’s one thing they really have cracked”
When asked directly, most said they would prefer to see a doctor or have an operation in Spain than in the UK. These ex-pats’ accounts of why they would choose Spain had some clues about not just why Spanish health care was so highly trusted, but also on a key question for the public sector: what fosters trust in health care more generally?
Perhaps British pensioners were simply reflecting on an objectively better health care system – Spain does punch above its weight in terms of health gain for the amount spent. However, for the older people in our study, trust did not seem to arise from direct experiences of better outcomes. Even when things had gone badly wrong – long waits for treatment, misdiagnosis, or, in one extreme case, the wrong eye being operated on – people repeatedly told us that they would trust Spanish health services over British ones. Poor clinical outcomes did not seem to dent their faith.
Two factors seemed to explain relatively low trust in the UK system compared with high trust in the Spanish system. For a community who largely read English language press and watched UK television, one was the seemingly unending succession of stories in some newspapers, especially those widely read by the ex-pat community, on the ‘failings’ of the NHS in England:
“There are people in the UK who have had problems being on the National Health and it is such a waiting list, they have died while they were waiting. It’s been on television many times, hasn’t it?”
They had little recent experience of the NHS to bolster their trust through personal encounters – and evidence suggests that it is personal experience with hospitals, doctors and clinics that fosters trust.
Second, their direct experiences of care in Spain were characterised by warmth at the personal level, and efficiency at the institutional level. Together, these features seemed to capture what a trustworthy system looked like.
As older citizens, our interviewees talked about the respect and care they had from all staff they encountered: doctors, nurses, receptionists, and cleaners were all described as physically demonstrating care through touch, and treating them with genuine empathy. This compared unfavourably to the UK, where they felt older people were marginalised in health care, and treated as ‘numbers’ not people. Alongside this warmth were very visible indicators of efficiency at the level of the institution. A key one was high levels of cleanliness observed in hospitals:
“You could eat off the toilet floor. It’s spotless, absolutely A1. If I had to give 100, out of 100, I would give them 110% … The place is like a clinic”
To describe a hospital as ‘like a clinic’ suggests something of what makes patients trust a health care facility: If it looks like a hospital, smells like a hospital, it is, it seems, undoubtedly a proper hospital. In the UK where, increasingly, publicly available ratings are used to inform the public about hygiene, clinical outcomes and risk, trust is, paradoxically, eroded. We are reassured by seeing a clean floor; we are not reassured by more information about cleanliness.
The study was done before the recent economic crisis really hit Spain, and in some areas there were sparkling new hospitals, with state-of-the-art facilities. However, it does suggest that more attention to the interpersonal aspects of health care, and less obsession with monitoring and audit, might do more for trust in the NHS.
About the authors: Judy Green is a sociologist at LSHTM, on twitter @judegreen. Helena Legido-Quigley is an Associate Professor at the Saw Swee Hock School of Public Health, National University of Singapore. She has conducted research on the impact of austerity measures on health and healthcare, and migrant populations. Her latest research focuses on health system reform in South East Asia. She can be found on Twitter @legidoquigley. Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine. He has published widely on European health policy. He can be found on twitter at @martinmckee.
4 Responses
Paul on Nov 20, 2015
I was wondering if it is possible that the participants felt compelled to justify their decision to live the ex-pat lifestyle – and hence valorised Spanish healthcare to support their decision, at the expense of demonising the NHS? The comments given seem very ‘black and white’ rather than compared and contrasted.
Judy Green on Nov 20, 2015
Hi Paul, thanks for the comment – we did consider this, and you’d maybe expect people to want to justify a big life decision to move abroad… but it didn’t explain why older people were still robustly critical of other aspects of the Spanish public sector, such as town halls… The comments may look a bit more black and white in a blog than in the full paper, but we were surprised at how positive participants in the study were about the Spanish system
Álvaro Rodríguez-Lescure on Nov 24, 2015
Wouldn’t it be easier to accept the Spanish Health Service does work better? What are your doubts about the outcomes? My British patients have access to drugs they never could receive in UK. Every time they come to my Service (Medical Oncology) they are surprised cause they are attended by a senior oncologist instead of a fellow or the nurse. Ten years ago some British women with HER2+ breast cancer (just not retired patients) came to Spain looking for Herceptin therapy in order to cure their breast cancer. They could not receive the therapy in UK.
So, perhaps, British patients express just simply their satisfaction since they feel they are receiving better health attention with no delays and with optimal protocols and drugs. Empathy and a nice and polite relationship are neccesarily appreciated by every patient, British or Spanish. My impresion is that of British patients do appreciate more and feel more grateful than Spanish patients. May be because Spanish patients are “used” to a good (although with many areas to improve) Health Service, meanwhile British are not. At least, that is what they use to comment.
Calum Macdonald on Oct 18, 2016
It’s difficult to generalise: Spain has a more devolved service, at both regional and local levels. Also, there are wide cultural and organisational differences.
Spain took the old UK NHS model as a starting point, but it is a more modern service by far. For example, few people in the UK realise that GP’s are not public employees: they refused to join the NHS at the start and have remained small shopkeepers (as Napoleon would have put it) ever since. They also have in the BMA the strongest Trade Union in the world. Most take home at least double the earnings of their Spanish counterparts but are nowhere near as efficient. Nevertheless successive UK governments have given them increased power, including financial control of much of secondary care services.
The UK public rate them highly because they are the last remaining corner shops.
Lord Darzi the former Health Minister, himself a world renowned pioneering surgeon, tried to modernise London NHS services: a main recommendation was to set up Polyclinics to increase efficiency and reduce the burden on hospitals, this is still a pipedream, but largely achieved throughout Spain.
At a cultural level family and community care features strongly in Spain: for example family and friends will be accommodated in hospitals and expected to share 24h care of inpatients together with professional staff.
Typically, there will be two patients to a room with ensuite, and two loungers for informal carers. Families and friends will share the care of a second patient with less or no informal help. This gives rise to an intimacy and collaboration that would shock many Anglo-Saxons, but it works.
I’m not surprised UK nationals living in Spain (the word expat is largely Anglo-Saxon and pejorative) give the Spanish NHS a higher rating than its UK predecessor. Simply put they are right!
I am a former Director of Social Services and so-called ‘subject-matter expert’, perrito as they would say in Spain, specialising in the management of long-term health and social care services. I have worked at local, regional, national and international levels.
I live in Spain mostly, as my wife is Spanish, but have friends and family in other countries where I have worked and been a consumer of healthcare. We have all lessons to learn from each other, but it saddens me that the UK appears to have lost its way recently.