Community action on the provision of cross-border health care (debate) 
President
The next item is the debate on the oral question to the Commission on Community action on the provision of cross-border health care, by Karl-Heinz Florenz, on behalf of the Committee on the Environment, Public Health and Food Safety B6-0013/2007).
John Bowis 
deputising for the author. - Mr President, I very much welcome this debate and the progress that is going to be made following the ECJ judgments, and I know that the Commission has this in its sights.
When I was in Potsdam in January for the German Presidency's first health conference, I very much welcomed the German Government's encouragement and its determination to see progress on the issue of patient mobility. We now look forward to the Commission taking that ship into the seas and bringing it safely to harbour for the benefit of our citizens.
In Potsdam, I quoted Jean Giraudoux, because we have a problem, and his quotation, I thought, symbolised it. He said '
Jamais poète n'a interprété la nature aussi librement qu'un juriste la réalité'.
Mr President, no poet ever interpreted nature as freely as a lawyer interprets the truth. And, with apologies to any lawyers who may be listening, it is a fact that the lawyers of Europe are deciding policy on patient mobility. Why? Because the politicians of Europe have failed to do so.
If you are happy with unelected lawyers deciding national and European Union health policy, then you do not need to do anything. Just wait and the bills will come in. But if, like me, you believe that it should be the job of parliamentarians, then we need to get on and give legal certainty and guidance without further delay in this whole area for patients.
But we need not panic. We are not talking about vast numbers. Most of our citizens prefer local options and, of course, language may be a deterrent to travelling very far. Only if we have waited too long are most of us interested in cross-border healthcare. Our preference is that local provision will improve and make patient mobility unnecessary and that, in a way, would be a good outcome of the ECJ judgments in itself. But we want to know how the new system will work in practice in case we need it.
We are not talking about a pan-European health service. We are talking about new powers for the patient to bypass sluggish and inadequate services locally and nationally. But, without clarity, without systems, without guidance, we are going to see major concerns as patients and their medical advisers seek to find their way through the complexities of the system, and health budget holders are in chaos as they try to cope with totally unpredictable demand for service funding.
So, as patients, as doctors, as managers, we need answers to some basic questions. The questions the patient asks are: Do I qualify? What is undue delay? Are there differences between conditions and between individuals, including the age of the individual? How do I apply if I need to? How do I or my GP decide what my options are? What country, what hospital, what specialist? What aftercare? Can I top up if the price is higher than in my home Member State? Who decides if the type of treatment complies with the new criteria? And I need to know before I go, not find out later. And how do I appeal if I disagree with the decision? Or do I have to go to court each time? Who will have access to checks on professionals? How will patient records be exchanged? Who pays for my travel, and for that of an accompanying person if I am a child? What channel for complaints is there if something goes wrong? How will reimbursement be affected? What will be the international interface between different systems, Beveridge/Bismarck, euro/non-euro zones? Do we need a central clearing house for claims and payments, nationally or for Europe? And lastly, is my mental illness also covered?
We shall need European legislation for some of these answers and national legislation for others. But above all we shall need guidance to provide clarity for patient and practitioner alike. We shall need to test the water and adapt to experience, such as with centres of excellence. We need to speed ahead with our frameworks for health professionals and patient safety and sort out the E121 system for people retiring abroad.
People have voted with their challenges to the courts and the ECJ has responded and confirmed their rights. Now we need political action to put in place a system which will be welcomed by people as a benefit coming from Europe.
Markos Kyprianou
Member of the Commission. Mr President, I am not sure whether I can say that we have come a long way since we first discussed this issue, but I can certainly say that we are on the right track. You will remember that our first discussion on this issue was even before the final outcome of the Services Directive. Parliament requested that a proposal on healthcare and health services should be brought forward and I promised that, as soon as the Services Directive was sorted out, I would do so. That is what I did last September in bringing forward this proposal.
Many issues have been described already and I will try not to repeat them. However, we tried to maintain, firstly, the special character of health, healthcare and health services in the European Union and to meet the challenge not only of achieving the social objectives, but also of benefiting from the internal market. It is true that the Court set out the parameters and the rights in its judgment, but I believe that those rights should be seen not as a problem, but as an opportunity and I tend to agree with that part of the motion for a resolution.
We have the realities before us, as described by the European Court of Justice. The point now is how to make them work for the benefit of patients, the Member States, national health systems and providers. We can do this not only for patient mobility, but also for all other aspects of cross-border healthcare.
I agree that the ultimate target must be that a European citizen should be able to receive the best healthcare where he or she lives. We should meet our aim of ensuring equality of health in the European Union. However, we know that this is a long-term objective and also that, under certain circumstances, it may not be possible, feasible or even desirable, depending on the financial, as well as - most importantly - the scientific aspects. Sometimes, we will still need to make use of the cross-border possibilities of healthcare.
As I have said, we launched the initiative in September 2006. The idea was to have a broad consultation, which ended on 31 January 2007. In the communication we described and analysed all the problems and issues, which are complicated. We have to follow a step-by-step approach. We will need a package to sort out and deal with all the aspects of cross-border healthcare, but that does not mean that we have to wait until they are all resolved before we present a proposal: we can do that in phases.
We are now in the process of analysing the contributions. We have had more than 270 from the Member States, from regional and local authorities, and from European national and regional organisations, representing patients, healthcare providers, health professionals, social security institutions, health insurance, universities, and hospitals, and even from individual citizens. Although I do not want to prejudice the results of the in-depth analysis, it must be said that the first assessment confirms the need for Community action to address the range of issues set out in the consultation paper, for example, legal certainty and support for cooperation between health systems. In addition, even though there are many different views on the details of specific aspects, the overall picture is clear: there seems to be potential added value for patients, professionals and health systems overall from some form of Community action on health services.
The Commission is in the process of analysing a summary of the report on all the contributions already published on our website. A summary report of the contributions will be drafted to provide an idea of the views and ideas sent in and should be available this spring.
However, the views and the input of the European Parliament are extremely important to us and will be a determining factor.
We will ensure that any future proposals on health services under this initiative are consistent with ongoing work on services of general interest and, of course, on the ongoing modernisation of the regulations on the coordination of social security systems. There has to be coherence and coordination among all these initiatives.
On the basis of the consultation and its outcome, the Commission plans to bring forward practical proposals later in 2007. Our aim is to find a solution which provides real added value without creating more red tape and which respects the principle of subsidiarity.
Françoise Grossetête
Mr President, Commissioner, we remember all of the debates that we had in our Parliament, during the debate on the Services Directive, to exclude health services. We felt that health was not a service like any other and that it was absolutely crucial to talk about it in a different way and, above all, not to regard health services merely as being an internal market.
Through its policies, the European Union is encouraging people to move around, and that inevitably has consequences for healthcare. It obviously has consequences for health professionals, who have demands in relation to legal certainty, and, of course, for patients, who are anxious to receive quality care. Hence there are a number of problems, as my colleague, Mr Bowis, has pointed out: language problems, the problem of monitoring care, the problem of the accountability of health professionals and of the quality of care. I think it important to say that patient mobility must not under any circumstances lead to the dumping of health systems, or make health care less secure. That is absolutely crucial.
Nor must the mobility of patients and health professionals create two categories of patient: those who can access other types of health care on the other side of the border and those who cannot. It would therefore be interesting to further develop harmonised health indicators at European level. The same goes for the completion of more exhaustive studies, which would enable us to better understand local needs and to do more to target those members of the public who are likely to seek treatment in another Member State, so that we can provide the most suitable legislative solution. To do that, we need a mechanism for gathering data and for exchanging information among national authorities.
Finally, we need to keep a close eye on the current excesses with regard to self-diagnosis and self-medication via the Internet, which knows no bounds. It is vital that we concern ourselves with patient information and have a genuine European label so that patients using the Internet can be provided with a viable form of security and information. Commissioner, rest assured that you will have our full support and trust for the proposal that you will submit to us shortly.
Linda McAvan
on behalf of the PSE Group. - Mr President, Commissioner, you know from our discussion in committee that this issue is extremely important for myself and for the PSE Group. We see health services as one of the pillars of the European social model, and the underlying values of that model - universality, access to good quality care, equity and solidarity, to ensure that services are provided on the basis of need and not the ability to pay - are fundamental to us and to that model. We feel that any initiative you take on cross-border healthcare should be built on these principles. It should be about healthcare for all and not about market opportunity for some providers. I think many other colleagues from different groups have already said this.
Mr Bowis talked about the legal certainty that is needed in a range of areas. These are the questions that people write and ask me about. They have heard about their rights, they are not sure how they can exercise them, so yes, we want a clear legal framework for patient mobility and for the movement of professionals, not just to give them rights, but so that citizens know that those healthcare professionals are properly qualified, are fit to practise and that information is shared between Member States.
Finally, Commissioner, you said that you recognised that healthcare has a special character. The health ministers agreed a set of values and principles in June last year, and I wonder whether you will be taking that on board when you draw up your proposals later this year?
Antonyia Parvanova
on behalf of the ALDE Group. - Mr President, we strongly support the Commission's consultation efforts and the European Parliament resolution outlining the main priorities for public health in the future Community framework. But we should think and plan more broadly: the final goal of future legislation should be better health for European citizens, not only when they cross the border, because by then it might be too late.
In addition to the resolution, I would like to call for your support on the following: basic standards for healthcare should be agreed in order to guarantee patients' safety and the quality of healthcare; the introduction of a common classification of health services, without interfering with Member States' competences on organisation, will create transparency for both patients and the financial institutions; and the 'one-stop shop' approach to be introduced in the Member States' health administrations will facilitate patients' choice and the right to complain.
The last issue I wish to emphasise is crucial for the full functioning of any new legislative framework on patients' rights: a common charter on patients' rights should be included in the future Community framework. Patients should be able to exercise their rights in the European Union regardless of the ownership of medical facilities, national social security schemes, organisational management of the national health systems or whether medical treatment is provided in the home country or in another Member State. All this is needed for a new European regulatory healthcare framework that would contribute to improving access to the best quality healthcare and to ensuring the safety and rights of all public and private patients in Europe, with particular consideration given to ethnic minorities - for example the Roma population - as well as refugees, migrants and the homeless.
Kartika Tamara Liotard
on behalf of the GUE/NGL Group. - (NL) Commissioner, the fact that thought is being given to cross-border patient mobility is, in itself, a good thing, but patient mobility, however, is entirely different from the mobility of commercial health services. These terms are too often mixed up.
Discussion of patient mobility should not in any event lead to the national healthcare systems being undermined or to Member States passing the buck in an attempt to make their own health care systems reliable, whether in terms of quality or quantity. Nor should it lead to the liberalisation of the healthcare market or force patients out of their own countries to seek care.
Patient mobility is a patient right and should certainly not become the excuse for applying the Services Directive to healthcare services. This House has taken a clear stand against this and would be robbed of its credibility if it were now to take a different line.
Urszula Krupa
on behalf of the IND/DEM Group. - (PL) Mr President, as I have only been allocated one minute's speaking time on the subject of cross-border healthcare, I shall be brief. I simply wanted to point out that, although this brings real benefits to a specific group of patients who are in a position to choose treatment in different Union countries, there are also unfortunately very negative consequences for certain healthcare systems, as well as for many patients from the poorer Member States. These patients' access to health services is restricted because of doctors' migration or for financial reasons.
For the wealthy old Member States of the Union, the priority is to improve the development, competitiveness and security of their own healthcare systems, which are described as European. The aforementioned countries take no account of the resulting costs to be borne by other far poorer countries. One cannot fail to notice in particular that the rich are becoming richer and safer, whilst the poor are becoming ever poorer. In addition, all this is being described in terms of sustainable development, equal rights and opportunities or as part of the principle of subsidiarity. The latter has had a regrettable consequence for European citizens, namely that the lot of the rich and strong is improving at the expense of the poor and weak.
Irena Belohorská
(SK) I regret to say that I regard the Commission's communication on healthcare services as unsatisfactory. The Commission has failed to come up with adequate and specific proposals for coordinating healthcare provision, since such service provision falls under the purview of national authorities. Furthermore, the communication unequivocally defends the notion that healthcare services should be regulated by the principle of free movement of goods.
In this regard I would like to emphasise that patients are not goods and healthcare professionals are not the same as other service providers. The European Parliament subscribed to that principle some time ago, as it excluded healthcare provision from the Services Directive. Despite the fact that cross-border health services only account for about 1% of healthcare provision, the Commission's communication focuses on patient mobility, cost refunds, etc. One should realise, however, that patients are not small-time traders and that patients do not seek healthcare abroad in order to generate savings but because such care is not available at home. It is therefore, quite unacceptable that Article 95, which regulates the free movement of goods, should be the sole legal basis of the future directive.
The Commission should focus on other pressing problems in the European Union. For instance, on why the mortality rate due to colon cancer is 40% higher in Slovakia than in Sweden or on how the EU could contribute to improving healthcare quality, for example through the use of structural fund allocations more efficiently for healthcare purposes.
I only wish patients could join forces with health professionals to bring about change as effectively as farmers can. Perhaps then we would see benefits going not only to farmers and cattle but also to human beings - in other words patients.
The Commission also draws our attention to recipient countries. In this respect I would like to highlight the countries of departure. In Eastern Europe we are beginning to see so-called white holes, or areas where there is a shortage of healthcare professionals.
Charlotte Cederschiöld
(SV) Mr President, I want firstly to thank the Committee on the Environment, Public Health and Food Safety for having put this excellent question to the Commission and providing the opportunity to hear the Commission's reaction to important questions put to it. It also gives those of us in the Committee on Internal Market and Consumer Protection the chance to put forward what we think is important. Health is an area in which the Member States have competence and in which the principle of subsidiarity applies. That does not, however, mean that people should not be entitled to health care and medical treatment in other Member States. We cannot maintain that we defend the patient's right to safe, high-quality care if we do not allow those who need, for one reason or another, to seek health care in another Member State actually to do so. We must do our utmost to preserve these rights, in spite of the various problems of which all Members are so well aware - problems, yes, but also positive aspects, especially on the information side.
It is also obvious - or, in any case, it should be - that the jurisdiction of the European Court of Justice cannot be weakened by secondary legislation. There is such a thing as established practice, and the Treaty gives everyone who wants to do so the right to make services available in another Member State, in full accordance, mind you, with the laws of that Member State. As I see it, the Commission should withdraw all legislation in which the Member States and the governments try to limit existing primary law for patients or service providers. It is important that the proposal produced by the Commission should be a step forward, rather than backward, and we have high hopes of Commissioner Kyprianou in this regard.
Bernadette Vergnaud
(FR) Mr President, Commissioner, ladies and gentlemen, health services, which have been excluded from the Services Directive, constitute a crucial pillar of the European social model. They contribute to social, territorial and economic cohesion, are a mission of general interest, and are also consistent with the Lisbon Strategy.
The Commission consultation must not be reduced to the free movement of health services, or aim at simply implementing an internal market in these services, as this would lead to a two-speed system, from which only the well-off and best informed patients would benefit.
The consultation must provide an opportunity to clearly define the role and added value of the Union, in order to guarantee a high level of health protection while respecting the national characteristics and powers of the Member States.
The mobility of patients and professionals must be guaranteed, with respect shown for the following fundamental values and principles: universality, solidarity, quality, security and durability.
It is imperative that a European legislative framework and, more specifically, a directive on health services, be adopted in order to increase the legal protection of patients, health professionals and health insurance systems and thus to restore the confidence of all Europeans in all Member States.
Thomas Ulmer
(DE) Mr President, Commissioner, ladies and gentlemen, health knows no frontiers, or at least, one hopes that that is the case. In exactly the same way health services should not stop at borders either, in other words, they should be of high quality and available to every citizen of the EU wherever he or she may be. We are now at the beginning of a debate rather than the end of one, so a vigorous debate is desirable and will get us where we want to go; health is not a commodity, and the internal market is, after all, no more than the space within which these services are provided.
These services need to be subject to special rules, with questions relating to the guarantee of quality provided, patients' safety, the safety of medicines and of medical products, to redress in the event of faulty or failed procedures, and to centres of excellence being examined in depth. The patient, who is to be protected, is the subject of particular concern, being, in cases of doubt, the weaker party, and often, indeed, the one who is at the mercy of others.
We are, as matter of principle, in favour of patient mobility and of the mobility of service providers, but reimbursement, which is a quite essential element in the cross-border trade in medical services, is subsidiary, and this has to be made plain right now, even though things are only at an early stage.
I do not, at present, see any chance of a European health insurance fund, and do not indeed think one is germane to our purpose, on the grounds that all the 27 national systems have their own problems, and, here too, where reimbursement is concerned, we are talking not about an open market, but rather about state-run and dirigiste systems.
In my own country, which has an extraordinarily complex system of payment to beneficiaries, such an opening-up would raise at once the discrimination against the country's own nationals, since the benefits paid are capped rather than open-ended.
It think it still appropriate that primary responsibility for this dossier should remain with the Committee on the Environment, Public Health and Food Safety rather than with the Committee on the Internal Market and Consumer Protection.
Markos Kyprianou
Member of the Commission. Mr President, I would like to thank Members for a very interesting debate, which will be very useful and will provide guidance for us in the next steps of drafting a proposal, along with the outcome of contributions from the other stakeholders, from consultations and from the Member States.
Just to cover a few issues: first of all, we will certainly be taking into account the health objectives and social values adopted by the health ministers last June, and this will be one of the considerations in our proposal.
At the same time, we will also be looking at the important issue of patients' rights, which is part of our consultation on Community action. It is clear that we will look at these issues; what tools will be used will, of course, be decided after proper analysis of the consultation and based on the responses provided.
I would like to confirm that what we plan to do is to take a step forward and not to reduce or undermine patients' rights as recognised by the Court, but to improve them and make them work, make them more concrete, and to make it possible to apply them equally among all European citizens. Information is an important factor in this respect.
As we have already stated, we will take subsidiarity into account. However, I have to remind you first of all that we do not propose harmonisation of national health assistance - this is not the intention. But, at the same time, I have to remind you of the European Court of Justice judgment on the Watts case, which provided that there are situations where Member States, based on other Treaty provisions, will have to apply to amend and adjust their national healthcare systems.
Finally, I think there is a misunderstanding here. First of all, there are no proposals in the communication because it is precisely a consultation document. We did not want to pre-empt the positions of Parliament, the Member States and the stakeholders, so it is intentional that there is no proposal at this stage. It is just a description of the problems. Freedom of movement and patient mobility is not something which is being introduced by the European Commission - I think we discussed that in the past as well - it is something which has been recognised, whether we like it or not - and I hope we like it! - by the European Court of Justice, which has established that the internal market rules apply also to health, even if this is publicly funded.
So this is not a question of a Commission initiative introducing a new concept but how we in the Commission, together with Parliament and the Member States, can make this concept, this reality, work for the benefit of patients without being to the detriment of the national healthcare systems, their viability and their operation.
This is a big challenge for us but I think it is a big opportunity as well, and we can make it work for the benefit of citizens.
President
To conclude the debate, I have received one motion for a resolution pursuant to Rule 108(5) of the Rules of Procedure.
The debate is closed.
The vote will take place on Thursday at 12 noon.
