Choice is one of the most powerful issues in the current debate over U.S. health care reform. Americans place great value on their individual ability to choose their own doctors, and they worry that existing employer-based insurance plans might be forcibly collapsed into a new public option (or cooperative) that would limit access to their current physicians or to certain types of specialists.

Since European health systems have been notably more successful than the U.S. in extending access and in constraining costs, it may be useful to examine their levels of physician choice. In practice, the amount of choice that European patients have depends on the country, whether the doctor is a primary care physician or a specialist, and whether the care is paid for by public funds (taxes or social insurance) or privately (private commercial insurance or out-of-pocket).

Primary care:

In countries with private general practitioners (including social insurance-funded systems like Germany and Netherlands as well as tax-funded systems like the United Kingdom, Denmark, and Norway), the citizen can choose his or her GP (sometimes with geographical restrictions, as in the Netherlands and the U.K.). GPs in the U.K. are known to be choosy about whom they take for new patients, however, and the patient’s choice of doctor also has to be approved by the regional office of the National Health Service, which is concerned about balancing the number of patients among GPs.

In the U.K., GP offices are now required to have night and/or weekend hours, with posted times when people can drop in without an appointment. Many offices have more than one GP (some are salaried employees), so it may be difficult to see “your” GP on any particular day. In the Netherlands, private GPs are required to establish cooperative agreements among their peers to provide night and weekend coverage.

In countries with publicly employed primary care physicians (Sweden, Finland, Spain, and Italy), the degree of choice is mixed. Sweden has started a movement (again) to have registration lists for primary care doctors inside the large health care centers where these doctors normally work. Individuals are allowed onto a physician’s list if there is room (there is a maximum number of patients allowed), however a patient may not be able to see that doctor on any given visit since Swedish physicians work 40-hour weeks with considerable educational and vacation leave.

Choice of primary care physician is more restricted in Finland and Spain, and it can depend on whether a visit is planned or not.

For acute care visits in Finland, Spain, and Italy, patients must see the primary care doctor on duty when they arrive (as with an HMO in the United States). In Finland, however, patients can use the separate social insurance to see any primary care doctor (including doctors who are publicly employed), with 20 percent of the fee paid by the social insurance. Patients in Finland can also see the occupational health physician at their place of work for free.

In Finland, there has been a longtime shortage of primary care doctors in the health centers (due to low pay). The problem has been dealt with in part by employing temporary doctors, especially from Estonia (attracted by what is for them is high pay).

Swedish primary health centers also have a longstanding problem with physician vacancies, and have been hiring Polish doctors to fill the gaps, particularly in rural areas. In both Finland and Sweden, people can schedule a planned visit with a particular primary care physician, but they may have to wait up to two weeks or more for the appointment.

Specialist care:

The degree of choice differs between countries with tax-funded insurance systems and those with social-funded insurance systems.

In tax funded countries (the U.K., the Nordic countries, Spain, and Italy), specialists are unionized public employees. For both outpatient clinic visits and planned elective inpatient procedures, patients have to accept whatever doctor is assigned by the clinic, including junior as well as senior doctors. As both Finnish and Swedish administrators like to say, “All our doctors are qualified – we trust our doctors.”

However, if patients pay privately in a public hospital (as is possible in the U.K. and Finland), they can choose their specialist. If patients go to one of the private hospitals (available in the U.K., Denmark, Sweden, Finland, Norway, Spain, and Italy), they can choose their specialist, even if the procedure is being paid for by public funds, and even if (as in Sweden) the specialist is usually a publicly employed M.D. who is doing procedures privately in his or her off-duty time.

In Germany and Austria, which are social insurance-funded countries where specialists are hospital employees, patients may be able to choose, but choice is not guaranteed. In Belgium and Netherlands, which are social insurance countries where specialists work in private group practices on contract to hospitals, most patients can choose their doctors. The exceptions are patients who are on public subsidy. e.g., indigent and/or elderly individuals.

What this brief survey suggests is that on the question of patient choice of physician (as elsewhere in health care) what counts are the details. While it is possible to have tax-funded and social health insurance-funded health care systems in which patients can select their own primary physician (e.g., the U.K., Netherlands, and Germany), such options may be substantially restricted by governmental regulation. Conversely, patients rarely have a choice of hospital specialists in planned elective or even outpatient clinic settings, regardless of how the system is funded.

Broadly speaking and with exceptions (where there are private GPs), there is considerable tension at present in European health systems between their prior existence as a uniform public service and growing demands from a more affluent population for more of an individual service. While different countries have progressed at different rates along this trajectory, there is a clear trend toward creating more personal service within these collectively financed health systems.

Richard B. Saltman is Professor of Health Policy and Management at the Emory University School of Public Health. He is cofounder of the European Observatory on Health Systems and Policies in Brussels and is currently head of the Atlanta hub He has published 16 books and over 130 articles and book chapters on a wide variety of health policy topics, particularly on the European health care systems. His new volume on Nordic Health Care Systems, co-edited with Jon Magnussen of Norway and Karsten Vrangbaek of Denmark, will be published later this month by McGraw-Hill Education. RSALTMA@​emory.​edu; 404–727-8743.