Social package (Second part: Cross-border healthcare) (debate) 
President
The next item is the statements of the Council and of the Commission concerning the Social Package (Second part: Cross-border healthcare).
Roselyne Bachelot-Narquin
President-in-Office of the Council. - (FR) Mr President, Commissioner Vassiliou, Mr Bowis, co-rapporteurs, draftsmen of the opinion, ladies and gentlemen, I thank the European Parliament for agreeing to defer our working meeting originally scheduled for the beginning of this month.
As you know, the French Presidency attaches great importance to consultation and dialogue on legislation. I felt it was essential to hold an initial exchange of views with my ministerial colleagues at the informal Angers Council on 8 and 9 September before coming before you to set out not, of course, the French position, but the position of the Council of 27 health ministers.
That first exchange of views, like the initial work done in the Council's working group on health, will not enable me to answer all your questions on this highly complex and varied subject but I am certain our sitting today will give the Commissioner responsible for health a chance to explain the European Commission's major decisions and allow me to share the Council's first impressions with you.
The Council supports the adoption of a directive on cross-border healthcare and patients' rights. It would be inconceivable to leave the decisions in this area solely in the hands of the Court of Justice of the European Communities. In my view, which I share with my colleagues, that should not be taken as a criticism of the Court or even of the content of its judgments, which often bring about major advances for patients. Nonetheless, it would be advisable for health policy in Europe to be developed by the two co-legislators, i.e. you and us, as the outcome of a political dialogue and a democratic process. It must be our common objective to build up a legislative framework that can contribute toward legal certainty.
Second point: in Angers, the delegations from the 27 countries all praised the quality of the work done over these past months and agreed that they had been listened to during the recent consultations. Commissioner Vassiliou was warmly thanked for that at the informal Council meeting. Indeed, the Slovenian Presidency will no doubt have informed you that the Council was very hesitant about the initial version of the text, the broad lines of which had been presented to the EPSCO Council of 19 December 2007. Only a small minority of states had supported that version. In fact, there was similarly great opposition to it in your Parliament, as MEPs confirmed to me during my preparatory consultations with the French Presidency in Strasbourg, Brussels and Paris. There is no doubt that the political dialogue Commissioner Vassiliou started as soon as she took office helped establish a sound basis for negotiation and the Council welcomes that.
Third point: with regard to the timetable, this proposal that the college of Commissioners adopted on 2 July came too late for us to be able to envisage a first reading during our Presidency, but we will press on with negotiations in the Council as far as we can, while entering into a political dialogue with the European Parliament. In that vein, the public health working group has already considered the directive on several occasions. It will be meeting again tomorrow to continue examining the text article by article. In this area as with our other political priorities, France will play its part in the presidential trio by working closely with the Czech Republic and Sweden. For the record, let me remind you that the subject of European health in the service of the patients has been a priority of our common 18-month programme.
Fourth point: regarding the scope of the draft directive, I know from talking to MEPs on the Committee on the Internal Market and Consumer Protection when they were in Paris last May that many of you regret the decision to confine this text solely to patient mobility and not to address the question of the mobility of health professionals. Given that I myself was an MEP at the time of the vote on the report by Evelyne Gebhardt and left Parliament just a few days before the debate on Bernadette Vergnaud's report, I well understand the reasons for that regret. Excluding health services from the directive on services in the internal market leaves a grey area that is not entirely covered by the current proposal for a directive, which only addresses patient mobility. One could even say that the proposal for a directive has more to do with the wish to incorporate and adapt Court of Justice case law than with excluding health services from the services directive and therefore with the demands by some MEPs for a specific sectoral instrument covering health services. There was no debate on that subject by the health ministers. Yet, in that regard, it is all a question of timetables and the European Commission's decision can be explained by the need to respond as rapidly as possible to the challenges that exist in the area of patient mobility, which already covers a very wide field. It is certain that a more broadly-based directive that included the mobility of health professionals would have had no chance of being adopted before the elections next June.
Fifth point: regarding the content of the text, we have not yet addressed all the proposed provisions. Nevertheless, the Presidency can say at this stage that in the Council's view prior authorisation for hospital care is a key question for EU Member States. It could even be described as the fundamental concern of health ministers. During the working lunch on the subject organised in Angers on 9 September, ministers who spoke were in favour of moving towards a better balance between the individual rights of patients to mobility and maintaining national regulatory and planning powers for the benefit of all.
The text reflects that improved balance, in particular by restoring the need for prior authorisation for hospital care. It is not a question of calling into question the case law of the Court of Justice, which specified how the principles of free movement set out in the Treaty applied to the health field, but of the need to incorporate in positive legislation the balance that the Court has already established in its case law between the principle of free movement and Member States' regulatory capacity. In fact, it distinguished between outpatient care, where the affiliation system cannot require prior authorisation, and hospital treatment, where the requirement of prior authorisation appears to be a necessary and reasonable measure.
At a time of serious budgetary constraints - ageing, technical progress - Member States must be able to be fully in charge of the care they provide in this respect, in particular hospital planning. As the Court itself recognised, one purpose of that planning is to ensure adequate and permanent access to a balanced range of quality hospital treatment throughout a national territory. It also forms part of the effort to control costs and to avoid, where possible, any waste of human, financial or technical resources.
I also want to point out that the requirement of prior authorisation ensures that cross-border care can be provided as soon as it is medically justified. In fact, the regulation on the coordination of social security systems already recognises this: authorisation may not be refused in the event that the same treatment is not available within a reasonable time. Nor must we forget that prior authorisation is also a protective measure for patients, since it ensures that any care provided in another Member State will be reimbursed.
Lastly, even if we keep to what we regard as the correct interpretation of the Court's case law, the directive would still offer great added value by clarifying the rights of patients, providing them with the necessary information and ensuring that this case law is interpreted in a uniform manner and is therefore applied universally and consistently in all the Member States of the European Union.
Thank you for your attention. I will be taking the floor again at the end of the debate to answer your questions.
Androula Vassiliou
Member of the Commission. - Mr President, I have already had the opportunity to discuss this proposal at length with various stakeholders and players in the decision-making process. You may recall that I presented the proposal to the Committee on the Environment and Public Health upon its adoption by the college and had a fruitful exchange of views. And I have also had the chance to exchange views with various national parliaments and, of course, the Member States in the context of the recent informal Health Council in Angers. It now gives me great pleasure to have this discussion, and I am looking forward to it with you, the honourable Members, in plenary. I take this opportunity to thank Mrs Bachelot-Narquin for the support and the chance she gave me to discuss this issue at length with the ministers.
I would like to put the proposal on patients' rights into context. Following the numerous discussions of the European Court of Justice on the question of the inherent right of European citizens under the Treaty to seek health care in the Member State of their choice and following the specific request by the European Council and the European Parliament alike to present a proposal to regulate the right after the health-care-related provisions had been taken out - and quite rightly so - of the Services Directive proposal, the Commission adopted the proposal on patients' rights in cross-border health care on 2 July.
It is without doubt the most important initiative on health of this present Commission. Its aim is to provide patients with better opportunities and access to health care, regardless of their place of residence while fully respecting national responsibilities over health-care organisation.
It has three main objectives: first, to clarify the conditions under which patients will be entitled to seek cross-border health care and be reimbursed and to make it effective, if this is the best solution for their particular situation; second, to ensure high-quality and safe cross-border health care throughout Europe; and, third, to foster European cooperation between health-care systems.
It is based, as I said, on the Court of Justice jurisprudence. It is fully in line with the Treaty, on the one hand, and, on the other hand, with the competences of the Member States for the organisation and delivery of health services and medical care.
The proposal is structured around three main areas.
First, it clarifies and reaffirms the common principles of all EU health systems: universality, equity, access to good-quality health care, and solidarity. It recalls the overarching principle underlined by the Treaty and the Court that the Member State on whose territory the health care is provided is fully responsible for setting the rules and ensuring compliance with these common principles.
To help the Member States translate this principle in more transparent terms, we have proposed to better clarify the objectives in terms of quality and safety standards for health care provided on their territory to patients from other Member States.
We also introduced a provision so as to ensure that patients from other Member States shall enjoy equal treatment with the nationals of the Member State of treatment.
Second, the directive clarifies the entitlements of patients and related conditions to receive health care in another Member State. For instance, for people in border regions, it may be easier to seek health care abroad rather than travelling long distances to the nearest relevant domestic health facility.
The added value of cross-border health care is also evident for people seeking highly specialised treatment, which only a very limited number of practitioners in Europe can provide. This might be the case, for example, for rare diseases.
The reality, however, is that most patients are simply unaware that they have the right to seek health care in another EU country, and that they are entitled to reimbursement for such treatment. And, even if they are aware of this right, the rules and procedures are often far from clear. This is what we aim to clarify with this new directive: patients will all get the same clear information and guarantees on cross-border health care.
In practice, as long as the treatment is covered under their national health-care system, patients will be allowed to receive that treatment abroad and be reimbursed up to the cost of the same or similar treatment at home.
We are also clarifying that, under specified circumstances, Member States are entitled to introduce limits on the reimbursement or payment of hospital health care obtained abroad through prior authorisation, if there is a clear risk - even potential - of undermining the national health system.
In addition to this, the Directive clarifies the definitions of hospital and non-hospital care and in that way simplifies the procedures and conditions to access cross-border health care.
In such a context, I would like to stress that we have maintained the possibility to expand the concept of 'hospital care' to some health care which does not necessarily require hospitalisation, but which is by nature costly or needs a heavy infrastructure to be properly delivered.
Third, the directive establishes a new framework for European cooperation in areas that we have identified as key areas for the future and where we must act together at EU level to better meet the challenges ahead of us. This is done in line with the principles I mentioned earlier through streamlined and improved cooperation, through common technical guidance and through a systematic search for best practices.
This framework will provide for developing enhanced future collaboration at European level in areas such as European reference networks, with a view to pooling together expertise, knowledge and medical skills, both for applied medical research and for diagnosis and treatment. In particular, this will be very important in the field of rare diseases, the provision of new therapies, as well as the rapid spread of new health technologies.
The second area is health-technology assessment, whereby the most efficient therapies will be identified at EU level by the best experts from the Member States, and spread in order to promote their use. Indeed, as regards new therapies and their high costs, the resources available being limited, we must ensure that they will be chosen and used in the most efficient possible way.
The third area is e-Health, where it is time to promote technical requirements to ensure interoperability at all levels and help to establish - at least - e-Health as an integral part of health-care services of tomorrow.
Fourthly, there is a need for a wider approach at EU level on the collection of health data related to cross-border health care in order to better monitor the effects of the proposed measures and enhance our epidemiological surveillance.
Finally, there is the facilitation of the recognition of medical prescriptions in all Member States. However, we must note that prescriptions issued in another Member State will be reimbursed by the patient's country of origin, only if the medicine is approved and eligible for reimbursement in his country of origin.
Let us also be clear that this initiative is not about harmonising health-care systems. It is not about changing roles in the management of health care. Member States are responsible for deciding how to organise their respective systems, what benefits they provide to their citizens and what treatments and medicines they will pay for. This will remain the case.
For now and for the future, what we want with this draft legislation is to grant patients the opportunities and information to access the safest, best-quality and most suitable treatment wherever that treatment is available in Europe. More cooperation between health systems will also create more solidarity and more health-care availability.
The aim of the proposed legislation is, indeed, to pave the way for better health care across Europe.
The directive is already being discussed, as was said by Mrs Bachelot-Narquin, in the Council, and I hope that the discussions will proceed swiftly in Parliament as well and that ultimately they will bear fruit.
(Applause)
John Bowis
on behalf of the PPE-DE Group. - Mr President, we all know that question on the doorstep: what does Europe do for me? Here is an answer: Europe is providing a new opportunity for patients. That is good news; we just have to make sure it works, and we will work together - the three institutions, and certainly within this Parliament - to make it work. But we are talking about court judgments. We are not talking about a blank sheet of paper, so we are not starting from afresh. We have to take into account those judgments.
Those judgments, in laymen's terms, are that, if you are facing undue delay for treatment, you have the right to go to another Member State, to have that treatment and have the bill sent back home, so long as the cost is comparable and so long as the treatment is normally available. That is straightforward. When I produced my patient mobility report in this Parliament, it was overwhelmingly accepted. Above all, we said, this must be a decision of politicians, and not of lawyers.
Mrs Bachelot-Narquin, to quote Jean Giraudoux, 'No poet has ever interpreted nature as freely as a lawyer interprets the truth.'
That is why we want politicians and not lawyers interpreting this. That is why we want legal certainty, so that everyone knows where they stand: governments, health services, patients, doctors. And it is why we must make it work for patients and for health services. It must be an opportunity and not a nightmare back home for health-service managers.
So we have questions. We have questions that the patient has the right to have answers to. Do I qualify? If I do, how do I proceed? What are the checks that I can carry out on where I might be going and who the doctor might be? What is the choice? What is the confidentiality requirement? And what happens if something goes wrong?
Those are all questions for which we must find the answer. And then there are issues we have to discuss among ourselves; some of them have been raised already.
Firstly, prior authorisation. My instinct is that, for in-patient hospital care, it is fair to have prior authorisation. The Court did not say that this was wrong in itself; it said it is wrong to refuse it under certain circumstances, so we need to look at that very carefully.
We also need to look at the issue of prescriptions. Yes, I understand that the home state must have the decision on what is prescribed, but if you are prescribed a course of drugs as part of your treatment in another Member State and you go back home and they say you cannot have the rest of that course, where does that leave the patient? That is the sort of question we have to answer.
Another issue is reimbursement. The patient does not want to have to go with a pocketful of cash. There must be a way of having the bill sent back home, I believe through a central clearing house.
But this is a measure for patients - not for services, that is for another day. It is patients who are at the centre of this - patients, not lawyers - and it is for all patients, not just for a few.
Dagmar Roth-Behrendt
on behalf of the PSE Group. - (DE) Mr President, ladies and gentlemen, we are speaking today about a proposal that truly does focus on people in the European Union, namely patients. I am very grateful to the Commissioner for her introduction, but I also wish to express my gratitude to Mr Kyprianou for all the groundwork he has done at a difficult time.
Why do I call it a difficult time? Because in many instances the Member States are still the last fossils left in this European Union, cast in stone, failing to understand that people are the focal point and believing that the world revolves around them and their systems. That is not the case. The focus is on patients, and they are the weakest links in our society, because they are ill and infirm.
If we talk about patient mobility today, knowing that it is actually a right in the internal market, which means that it ought to have applied for more than twenty years, we should consider whether this is a timely debate and whether the Member States are abreast of the times. I tell you they are not! If the Eurobarometer is showing us today that 30% of all people in the European Union are unaware of their right to obtain treatment outside their own country, this means that all the Member States have been getting it wrong. They have not informed people of their rights; they have not been telling them what they are entitled to do and which options are open to patients.
Yes, I share the view of Mr Bowis and others here, and the Commissioner too, that the Member States should certainly retain their autonomous health systems. We have no wish to interfere with that, but we also want to ensure that patients have freedom of movement.
In connection with Member States' autonomy, I also recognise the need to be able to plan ahead, particularly when it comes to in-patient treatment. For this reason, authorisation will have to be one of the main topics of our discussions. Mr Bowis has already made that point.
Networks and information points must ensure that patients know what they are allowed to do, but they must also know where the best treatment is available - whether it be in Germany or in Cyprus - so that patients also have the opportunity to be cured.
If we succeed in improving the quality of health care and people's access to health care close to home, that will surely be a marvellous achievement, and no one need shop around anymore. That is what we really want.
Jules Maaten
on behalf of the ALDE Group. - (NL) Mr President, Commissioner Vassiliou, Minister Bachelot-Narquin, last week I attended a presentation of a new website on patient rights in all the EU languages, organised by my Danish colleague in the ALDE Group, Karen Riis-Jørgensen.
There was a lady there from Denmark who very nearly might not have been. She had breast cancer and was not getting anywhere under the Danish system because she had the wrong number of tumours. If she had had five tumours she would have been treated, but she had seven and did not qualify under the criteria. So somehow or other she needed to get rid of two tumours before she could be helped. In short, an unending struggle. In the end she found help in Germany. She did it - she borrowed money from friends and family and went to Germany where she was helped. Her secondaries have now disappeared. She is cured, to the extent that you can ever say you are cured of cancer.
It is inhuman to make someone like that, an individual, battle against a system at a time when they are sick, at a time when they are as weak as they could possibly be. That is putting the system before the patient. I find it totally unacceptable! The Danes did in the end pay for much of the treatment, and all was well in the end. But what that woman had to go through was not exceptional; it happens all too often.
So the European Commission's proposal is a huge step forward to help these patients and my group is very keen to support it. We also need to ensure that this debate does not turn into an ideological debate. This is not just another directive about health services. This is not about how to reform health in the European Union. It is not about whether or not there should be a free market in healthcare. To my mind it is not really a matter of subsidiarity either. The question is not whether the Member States prevail or the Union. No, the question is whether or not the patient wins out. That is all that matters really. We shall definitely have to talk about all these other things, perhaps argue about them robustly during the election campaign, but in my view and that of my group they are not our concern today.
We are not trying to harmonise health, now is not the right time for that and maybe it cannot be done anyway. But we must learn to make use of the opportunities which the European Union offers us, the economies of scale we can benefit from, so that real specialist help can be provided to people with rare medical conditions. That possibility has of course existed for years, but now we really can make use of it and we must.
To conclude: last week Parliament also held a meeting hosted by Dagmar Roth-Behrendt at which the European Patient Forum outlined its manifesto. I am glad to see patients banging the drum, because it is patient input that we need. We are poised now to take a democratic decision, following the lead given by the lawyers. But the decision will now be taken by the right people, namely the elected representatives of the people.
Ryszard Czarnecki
on behalf of the UEN Group. - (PL) Mr President, it is a shame that we did not have the opportunity to discuss this particular issue during the previous session, when we were discussing the two previous legislative proposals. But, as the saying goes, better late than never. We are pleased to see that the Commission's proposals really do go in the direction requested by the European Parliament, in the direction in which the European Parliament encouraged the Commission to go in this regard.
If Europe is really to be a Europe without borders then this has, first of all, to be in the area of healthcare. Guaranteeing healthcare to the inhabitants of our Member States will show that we have really done something for European taxpayers and voters. After all, what the average Pole, as well as the average Hungarian, Cypriot, Englishman and Italian are interested in, much more than the Lisbon Treaty, is whether they will be able to access healthcare abroad during their holidays, or even if they can make a special trip to take advantage of a highly specialised hospital.
Finally, I believe that the measures that we are discussing today could really improve healthcare for foreigners and at the same time increase the authority of the EU, an authority that has recently been shaken by ideological debates and by trying to impose unwanted institutional solutions onto EU citizens.
Jean Lambert
on behalf of the Verts/ALE Group. - Mr President, I welcome very much the statement that has been made, certainly, by Council on this particular directive and the limits and context of it. As Parliament's rapporteur on the update of the coordination of social security, and indeed its rapporteur on the implementing regulation, I have a very specific interest in this because questions about reimbursement - how it is provided, what information is given, the speed and method of it etc. - come within the scope of that particular regulation. I think that when we are talking about issues such as health care for people who are on holiday elsewhere in the European Union, we should remember that comes under the European Health Card and under the coordination of social security. That is clear.
What this directive is aiming to do is to pick up some of the issues which are not necessarily dealt with in that particular regulation, and I think we need to be careful where the dividing line is on that. The question of prior authorisation has of course been an extremely important one. I think we need to be clear that we are not talking necessarily about an absolute right of patients to move and be treated within the European Union under their national systems, in terms of their national systems reimbursing them. It is a qualified right and I think we need to be clear on that.
I think we also need to be clear that what this directive is proposing, as I understand it, is that what will be paid for is care that will be available under the national system, not new or different treatments, so that again qualifies the right that we are talking about in terms of this particular directive.
There is no question that prior authorisation needs to be managed better, and that not only the patients but also the administrations involved need to understand what that is and how it should operate speedily in terms of medical need. That is the criterion set down by the Court: medical need. Administrations therefore need to reflect that, not necessarily their own cost basis.
There is a lot to be welcomed in this directive, and issues around best practice, issues about quality, legal certainty, who is responsible, are also important. As John Bowis has mentioned, we also need to take steps forward on questions, for example, about continuing care or prescriptions which may not be valid in one Member State because of their own systems. But we also need to be careful - and this applies to the implementing regulation on 883, as it does to this - that we should not be in the business of helping patients make a profit by playing different systems off against each other. I do not think that health-care systems benefit from that whatsoever.
I want to make clear on behalf of my group that increasing the amount of cross-border care is not of itself a goal. Mrs Roth-Behrendt said that most patients wish to be treated at home and have the quality and speed of treatment there, so increasing the amount in itself, as I say, is not a goal. A lot of claims are being made about the effects of trying to increase the amount of cross-border care which I think we need to be wary of, and I am glad the debate has reflected that.
There are people who are arguing that this introduces competition, that this drives up national standards, and that we even need to open the market as a reason for actually increasing and encouraging cross-border health care. However, this Parliament has made its position very clear: health is not a service like car insurance. It has a very particular role and its users are not simply consumers, but people in need and potentially vulnerable.
Many of those who tell us that increasing cross-border health care is a good thing will also reassure us that it only covers 2-3%. I want to know what the estimates are for the future and what the effect of this will be on the 98% of people who do not move and currently do not want to.
Roberto Musacchio
on behalf of the GUE/NGL Group. - (IT) Mr President, ladies and gentlemen, I am sorry that I cannot share the optimism of fellows Members, since I am convinced that this directive may well do more for business than for health: a kind of Bolkestein directive, but on health.
The crucial point for Europe has to be that every citizen must have the right to the best possible treatment in his or her own country; the sacrosanct right to be treated anywhere will otherwise mask the fact that treatment is not available at home - something that cannot be put down to questions of subsidiarity. It also masks the interests of those keen to speculate on health, providing big business for insurance companies and increasing costs for citizens as well as European health spending.
A directive which is, in my view, mistaken, because it pays no attention to harmonisation, to the universal nature of the service that Europe must ensure, and is not based on the notion that health is a right which has to be guaranteed by the public sector and not left to people's ability to take out private insurance. The unions are rightly very concerned and we are concerned with them.
Derek Roland Clark
on behalf of the IND/DEM Group. - Mr President, the central feature of this package - travelling for non-hospital treatment outside the home country - is funding by the home country, but limited to the amount it would have cost there. So there are benefits in going to a country where treatment is cheaper, as long as it is better. Health tourists will have to find the difference between the costs where treated and the home country's base of provision. Yes, travel costs are paid, ultimately by the home country, but at the home country's own level, leaving the health tourist to find the treatment top-up and probably travel cost excess. The poorest cannot afford to do this and they are left with the lowest standard of treatment. The rich can do it, but they will probably go for private care anyway. Regarding waiting lists, if a country's health care is poor and expensive they will not be troubled by health tourists, but where it is cheap and good they could soon be overburdened. This, therefore, produces a two-tier health care system. Is that what they call an unintended consequence?
Luca Romagnoli
(IT) Mr President, ladies and gentlemen, four out of every hundred citizens in Europe go abroad for treatment; in my view, however, health tourism is symptomatic of local shortcomings and a lack of services. The Italian health service spends some EUR 40 million a year on Italians who go for treatment in other countries, and that obviously does not include private insurance.
What are the reasons for this? Without a doubt the very long waiting lists for services. In Italy, for instance, people have to wait 300 days for a prostate operation and very often a month or more for a CAT scan. Secondly, services such as dental treatment and cosmetic surgery have to be paid for in Italy and not in other countries. Thirdly - and I draw everyone's attention to this - people go abroad to take advantage of techniques such as artificial fertilisation which are prohibited or partly prohibited in their own countries, or which are absolutely illegal as in the case of purchase of live organs - while India is a sad example, there may well have been equally sad examples in other countries before their accession to the Union.
All in all, people decide to embark on health tourism because high-quality and less expensive services are on offer; in many cases, however, I feel that supervision by the Union needs to be tightened up both as a guarantee for consumers and to ensure that competition is on an equal footing. The social context in which services are provided is often a mixture of public and private, in those countries which have recently acceded as well, and, Mrs Vassiliou, I would therefore recommend, over and above the principles on which you have focused, strict supervision of compliance with existing regulations which make the use of raw materials, the CE mark and conformity documents compulsory, because the salubriousness of medical devices and treatments has to be guaranteed. Let us not forget that there is always someone ...
The President cut off the speaker
Charlotte Cederschiöld
(SV) Mr President, Commissioner, Minister, now we European parliamentarians have a chance to show that we are just that, European parliamentarians. That we are standing up for the Treaty and the rights it gives us. That we are legislating with the patients' best interests at heart, not to protect and support the protectionism which sometimes informs the debate. That we are committed to finding added value in cooperating to give our patients the best possible care, wherever that may be.
The proposal that Commissioner Vassiliou has presented is a good starting point and to be applauded. We must complete what she has begun and ensure that no unnecessary bureaucratic obstacles are introduced. To spell it out, that means that the Member States have no right to prevent free movement without reason. Requirements for prior authorisation may be imposed only in exceptional cases - if they are specified on the Commission's list or if there is a risk of a mass exodus of patients which would undermine the health system. The idea that it might be imposed because so few patients have chosen to seek care abroad is highly unlikely. Thus the starting point is: no prior authorisation. Anything else would be contrary to the Treaty.
The next stage in this work on creating the conditions for optimum care is to implement the directive correctly. Sick people should not have to go to court in order to validate their rights and to get unjustified requirements for prior authorisation overruled. The Court of Justice will rule in favour of freedom of movement, but at what cost in terms of money and the health of patients who have to seek enforcement of their rights every time! I really hope that we can escape that experience, and I call on my fellow Members and the President-in-Office to help us; I am quite convinced that our Commissioner will help us.
Bernadette Vergnaud
(FR) Mr President, Mrs Bachelot-Narquin, Commissioner, ladies and gentlemen, following my own-initiative report on health services that Parliament adopted on 23 May 2007, the Commission is now proposing, as part of the social package, a directive addressed solely at patients' rights in regard to cross-border health care.
I am, therefore, very sorry this text shows so little ambition and does not take account of the many internal challenges that need to be resolved in order to combat the growing inequalities in the health sector, such as the ageing population, social inequalities, geographical segregation and medical demography problems. On an issue that is so vital to the citizens of Europe, the Council and Parliament cannot, therefore, simply codify the Court of Justice's rulings. We need to find a certain balance, which will safeguard both the rights of patients - who are not merely consumers - to cross-frontier care, and equal access for all to quality care, with solidarity-based responsibility; to ensure social and territorial cohesion and respect for the principle of subsidiarity. There is still a worrying grey area in relation to definitions, such as prior authorisation and the concept of hospital care. We need clarification here, so as not to open the door to discrimination that might give rise to a two-speed health system within Europe instead of creating added value in Europe.
Health has no price but does have a cost; the directive, on the other hand - and that is a good thing - reaffirms both the principle of subsidiarity and the need for closer cooperation to bring the medical research networks and patient information centres closer together.
The debate will begin; it must be an in-depth and fruitful debate, rather than a precipitate one, and must be shared by all the players involved, with the object of constructing a genuine European social model.
Elizabeth Lynne
Mr President, why should a patient have to lose their sight waiting for a cataract operation in the UK, for instance, when it could be done in another Member State? And why should a person waiting in agony for a hip operation not be able to take advantage of the lack of waiting lists in some Member States, sometimes at a lesser cost to the country of origin? And why do some heart patients have to wait months to have surgery to unblock arteries when there really is no need?
If a clinician advises treatment, and this cannot be provided at home, then we need a legal framework to ensure that we can seek it elsewhere. All too often it is the poorest people that face discrimination and inequality in access to health care. That is why we must ensure that Member States can authorise treatment in another country prior to that treatment. We must not restrict cross-border health care just to those who can afford it.
Equally, this new directive must not compromise standards of care for those people who do chose to stay at home. We must also ensure that there are safeguards in place that put the rights and safety of the patients first. That is why it is vital that a mechanism is developed to share patients' records between the patients' home country and the country where they receive treatment.
Apart from that, we need to develop a system of compensation for patients who suffer avoidable harm when being treated in another country EU country. And, with regards to the sharing of best practice, I welcome Article 15 in the draft directive which calls for a system of European reference networks. These centres of excellence could prove a useful way of sharing knowledge, training and the exchange of information. All too often we look at health-care-acquired infections or cancer-screening guidelines; the answer is on our doorstep, and it is about time that we started learning from each other more effectively.
Ewa Tomaszewska
(PL) Mr President, the main healthcare challenges facing us today are improving the health of older people, preparing to deal with geriatric diseases in relation to the ageing population, universal access to a proper level of healthcare, ensuring financial stability for national healthcare systems, giving particular attention to access to healthcare for disabled people, children, the elderly, and those from poorer families, guaranteeing the rights of the patient in cross-border healthcare, establishing cross-border electronic interoperability for medical records, while at the same time ensuring protection for personal data and the provision of good working conditions for employees in the healthcare sector.
The concrete measures proposed in the Social Package to meet these challenges, such as the preparation of a communiqué concerning meeting the needs of the ageing population, or the preparation of a green book as regards the issue of employees in the healthcare sector, give us some hope that we shall not remain only at the wish-making stage. I am glad to see that so much attention has been paid to the issue of cross-border healthcare, which is so important in this age of ever growing migration.
(The President cut off the speaker)
Eva-Britt Svensson
(SV) Mr President, the directive means that more power will be given to the EU over healthcare, and I am opposed to opening up this field to EU legislation. Healthcare is and must remain a national prerogative. The idea that patients should engage in a form of healthcare tourism is an incorrect prioritisation of our common healthcare resources. The new fundamental principle that we should have a right to care in another EU country without prior authorisation opens up a fast lane to care for young, linguistically talented and relatively healthy persons and poses the risk of diverting resources from those with greater care needs, such as our elderly and those with functional impairments. Clearly everyone should have the right to care if they are sick in another EU country, but we already have that right without the need for new EU legislation in the field. Healthcare remains a national policy area.
Hanne Dahl
(DA) Mr President, we all wish for the fastest, best treatment if we should fall seriously ill, but I do not want to see the American model, where well-off citizens receive the best treatment and vulnerable members of society second-class treatment - if they are lucky. If they are unlucky, they receive none at all. Therefore, we must lay down some basic principles. There should be free and equal access to healthcare services for all, and people should be treated in turn and according to need. That is to say, a public authority must carry out an assessment to ensure that a medical professional determines what constitutes 'turn' and 'need'. It is the sickest who should be treated first, not the richest. A way forward in terms of free and equal access to healthcare services for all citizens would be to scrutinise public contributions to treatment in private hospitals and tax credits for private health insurance. EU legislation should not be oriented towards an ideological school of thought based on the internal market, but should aim towards a flexible system in Europe, which guarantees minimum rights for all citizens in terms of treatment.
Irena Belohorská
(SK) The directive on the application of patients' rights in cross-border healthcare endeavours to solve an acute problem.
This problem is the conflict between the subsidiarity of healthcare systems and the right of European Union citizens to free movement, and also their fundamental human right of access to health services. Free movement is the right of any citizen living in a Member State and his health moves with him. Should he not be able to approach health services, he would face a serious obstacle hindering his free movement. Complete equality of services is impossible because of different taxes paid in individual countries in respect of health services, as well as differing rates of treatment in individual countries.
Although many politicians worry about the onset of health tourism, especially from the East, their fears are unsubstantiated. A very important thing for a patient is to be close to his relatives and not to face a language barrier. The patient-doctor relationship is very specific. The success of treatment partially depends on a patient's trust in his doctor or in the health establishment. A patient's readiness to travel abroad to get treatment depends on the seriousness of the illness. In cases of life-saving treatment or treatment of a serious illness, no other obstacles matter.
I think it would be preferable for these issues to be dealt with by the European Parliament rather than by the European Court of Justice. It is sad that, although we are the citizens' representatives, we find making decisions more difficult than the European Court of Justice which, in each case so far, has found that the patient was right.
I should like to mention one thing in conclusion. Many of my fellow Members talk about the rich and the poor. For me, as a doctor, there is only the patient. I do not care whether he owns a Ford or is homeless.
Ria Oomen-Ruijten
(NL) Mr President, to begin with, may I say how delighted I am to see our erstwhile colleague, Roselyn Bachelot, here with us today and hear her telling us once again that the European citizen is all-important. This piece of legislation reflects that emphasis. My compliments also go to Commissioner Vassiliou, who has seen this very difficult item of legislation through.
With this legislation we - the European Parliament, the European Commission and the Council - really are doing something for people. The directive provides legal safeguards for mobility and at the same time offers a statutory basis for existing initiatives in the area of cross-border healthcare.
But when I compare this directive with the earlier versions, those which were opposed, I see that the focus is now more on patient mobility and less on health services, and the reason for that is to keep the Member States happy. I have a word or two of criticism about that. Border areas that have already taken some good initiatives on cross-border healthcare - for example the cooperative arrangement between the Universitätsklinikum Aachen and the Academisch Ziekenhuis Maastricht in my own province of Limburg, which as part of the Meuse-Rhine Euroregion would dearly love to be a pilot area - are becoming far too dependent on mobility alone and thus on the whims of insurers or the goodwill or otherwise of national authorities, because the focus is now no longer on the services themselves. We should take a good look at Article 13 to decide how we can get regions working together a lot more. And whilst I am on the subject, Commissioner, may I make the point that we in the Meuse-Rhine Euroregion are very keen to be a pilot area.
Secondly, patient involvement in setting up national contact points. Mrs Schmidt in Germany has taken an excellent initiative on this and we should look at how we might tie that in more closely to our own wider plans.
Another point is the 'list of treatments, other than those requiring overnight accommodation, to be subject to the same regime as hospital care', the purpose of which is to exclude certain functions from this directive. This needs careful consideration too, because we cannot have a situation where an overly strict interpretation of that list rules out cooperative ventures of the kind I mentioned just now. It is most important to know that effective cooperation makes centres of clinical excellence cheaper, not more expensive, and more readily accessible to people. That, after all, is what we are aiming for.
Anne Van Lancker
(NL) Mr President, Commissioner Vassiliou, Minister Bachelot-Narquin, Europe has an important duty to help guarantee everyone high-quality and affordable healthcare, close to home if possible or abroad if necessary. So I am very grateful to you, Commissioner, for your initiative which unquestionably has many positive aspects in terms of guaranteeing quality and safety, information to the patient, more European cooperation, e-Health, reference networks and so on.
I also agree with you, Minister, when you say that it is not a good thing to leave rulings on patient mobility to the Court of Justice and that there is a need for legislation here. I agree too with the view of Mr Bowis and Mrs Lambert that we ought perhaps to think about a better balance in the matter of prior authorisation of patient mobility, because that prior authorisation is an important instrument of Member States' planning and policy.
A few other questions remain, Commissioner, about the fees to be charged, and mechanisms to prevent patient mobility leading to waiting lists in certain countries. But I am sure, ladies and gentlemen, that these are questions and concerns which we shall be able to resolve as we discuss this directive further.
Once again, thank you for your initiative, Commissioner. And we look forward, Minister, to cooperating with you.
Marian Harkin
Mr President, at the beginning of this year I conducted a number of consultation meetings throughout my constituency in the context of EU policy on social issues, and then these meetings fed into the Commission consultation on social reality stock-taking.
It was very clear to me that citizens are very interested in the EU becoming more involved in social policy, and that certainly includes patient mobility. Indeed, the call for more social Europe was reinforced during the Lisbon Treaty campaign, and this response from the Commission, while not fully addressing the concerns of citizens, is timely and a step in the right direction.
I certainly welcome the proposals on patient mobility, but agree with some of the previous speakers that very many issues still need to be clarified - in particular, the issue of prior authorisation.
However, the bottom line is that patients must be at the core of any policy and should have no worries about costs, safety and quality.
In the mean time, patients must be fully informed of their existing rights, since legal uncertainty always works to the disadvantage of individuals who do not have many personal resources.
Finally, the French presidency referred to the fact earlier that some people will be disappointed that the issue of the mobility of health-care professionals has not been dealt with. I am one of those people. If we are to put patients at the core of any policy, then patient safety is paramount, so we must establish standardised accreditation systems for health-care professionals throughout the EU.
Zbigniew Krzysztof Kuźmiuk
(PL) Mr President, speaking in this debate I would like to say that, from the point of view of the new Member States, it is important to leave the possibility of introducing restrictions on the use of healthcare abroad to the national level, principally because of the insufficient funding allocated to healthcare in these countries. Similarly, it is essential to apply the principle that a patient has the right to a refund of costs up to the value of what would be paid if the patient had used healthcare in their own country until such a time as the differences in development between the old and the new Member States have become significantly less.
Finally it is worth emphasising that the proposed solutions, particularly as regards the introduction of the European Reference Network, and also the European Network for Health Technology Assessment, provide an opportunity to raise the standards of medical care and also to make more effective use of healthcare resources in the European Union.
Jiří Maštálka
(CS) Ladies and gentlemen, as I am sure you know, the slogan of the upcoming Czech Presidency is 'Europe without barriers'. In this context I am glad that the Commission, in cooperation with the European Court of Justice, was able to put forward a proposal that breaks through one of the barriers, namely healthcare provision. I approve of the fact that, thanks to the negotiations that have taken place so far, citizens are closer to a solution. Being a physician, I should like to see the necessary documents adopted as soon as possible, but I assume that the matter is so complex that the old Roman adage of 'hurry up slowly' applies here. At present, I think that the following fundamental issues should be debated. Firstly, we all agree that it is necessary to ensure legal protection for patients who have the right to healthcare within the European Union, in keeping with the judicial decisions of the European Court of Justice. Secondly, it is not possible for the directive to establish new competences for the Commission because they are not vital. Thirdly, I think it is erroneous that, although the basic purpose was to ensure free movement of medical services, the text of the directive itself concentrates, first and foremost, on movement of patients in need of non-urgent healthcare. Further debates represent an opportunity not only for the Czech Presidency but also for Europe.
Kathy Sinnott
Mr President, I am both looking forward to and dreading the cross-border health directive.
I am looking forward to it because I know so many people who are more disabled, and so many people who have died, as a result of a long wait for treatment in Irish public hospitals. So the thought that my constituents will be able to get their medical records and travel without the current prior authorisation obstacle presented by the E112 scheme, to go and get treatment promptly, is wonderful. I will certainly be advising those of my constituents who can travel to do so.
However, I am also aware that this will further exacerbate the problems in the Irish health system, and for those who cannot travel, and who must rely on that health system, I am in dread.
Gunnar Hökmark
(SV) Mr President, this issue is about the right of the individual to seek healthcare where good care is available. The representative of the Group of the European United Left, Eva-Britt Svensson, said here earlier today that it will lead to healthcare tourism. I would like to inform her that, when sick people seek care, it is because they are in pain, they are suffering, they are damaged, and they need care. It is not about tourism.
Ultimately, this question is about the power of bureaucracy versus the right of the individual. It is about whether old frontiers should be used as a barrier to people seeking healthcare or whether the openness of today's Europe should be used as a means for people throughout Europe to get the best healthcare they can. It was illuminating to hear what the Group of the Left thinks but, since I have the representative of the Social Democrats, Jan Andersson, in front of me and he is right after me on the speakers' list, it would be interesting to hear from him whether he shares Eva-Britt Svensson's view that sick people who seek care abroad are engaging in healthcare tourism. Does he, like her, want to erect barriers of various kinds or will you, will the Social Democrats, work to ensure that we have the greatest possible openness, in which patients do not need to ask permission from the authorities to get healthcare? This question, Jan Andersson, is about Social Europe. It is not about how individual decision-makers should determine what others can do, but how the individual can get the best healthcare. Over to you, Jan Andersson.
Jan Andersson
(SV) Mr President, Commissioner, let me especially welcome Mrs Bachelot-Narquin. We have worked well together in the past and I hope that we shall do so in the future. Welcome to Parliament. Briefly to Mr Hökmark, this is not a domestic debate. I do not check my opinions with Mrs Svensson, I prefer to form my own.
I welcome this directive for several reasons. We need clarification in legal terms. I think it is better than the draft that we had previously. There are considerable advantages, particularly for people who live in border areas, as I do myself. That said, I would also point out that it is important to link the arrangements to the various systems around Europe, in terms of organisation, financing and similar aspects.
There is one aspect that we must pay particular attention to. That is equality. We know that there is prioritisation in healthcare, but it is important that people are all treated equally and that some should not be able to take precedence because of their resources, and it is important that we should be able to combine these two aspects in cross-border care. The question of prior approval is also important. That is something to which we must devote further discussion. The limit specified in the directive is not good. Inpatient care, outpatient care: it varies considerably from one country to another, and the pattern changes over time. We must find other criteria. I look forward to cooperation. In our committee we shall be dealing with the financing of social security systems, which forms part of this cooperation. I look forward to cooperation with the other committees on this matter.
Anneli Jäätteenmäki
(FI) Mr President, the most important thing is for patients to receive good, safe and cheap care, and more often than not they want to receive their care as close to home as possible. In other words, national healthcare services need to be delivered appropriately.
The Commission's proposal before us should nevertheless be welcomed. It is important that care and treatment can also be available in another country. That would ensure more freedom of choice and that there were clearer guidelines and advice, whilst health and safety issues also become clearer. For patients, then, this would be a good thing.
For the Member States the issue is slightly more complicated, because the directive cannot work well until the electronic social welfare and healthcare systems in the Member States of the Union are compatible. We know that they are not today, and the implementation of this directive would demand a lot from the Member States. We need to ensure that when the directive has been adopted it also means that patient's details can pass from one system to another, information security is guaranteed and the patient's safety is assured. The patient is what is most important.
Søren Bo Søndergaard
(DA) Mr President, the road to hell is paved with glittering promises, and one does not need to be a professor to foresee the result of this proposal in its current form. On the one hand there will be an 'A team' consisting of the wealthy, the well educated and those with the right connections - generally speaking, all of us in this Chamber. We are to be able to jump the waiting list in our home country and seek out the best experts in the EU - as we can afford to spend money on treatment, and we can afford the travel and other additional costs. On the other hand there will be the poor and underprivileged. They are allowed to join the back of the queue and, when it finally comes to their turn, they obtain the treatment that we, the richest, did not want. On special occasions, the EU presents itself as an alternative to the United States, but the point is that the EU is increasingly resembling the United States - including in the health field. Our group supports free and equal access to the treatment people need, so we reject this proposal.
Alojz Peterle
(SL) The social landscape of Europe has changed. We are faced with new challenges which require a modernisation of the European social model. The healthcare landscape of Europe is also changing. Success rates in the case of some diseases are on the increase, as is spending on running healthcare systems. However, citizens encounter huge differences in the quality of healthcare, both between the Member States and within them. Cancer survival rates differ by as much as 10% between the Member States.
I welcome the European Commission's intention to look closely at the issue of healthcare within the framework of a renewed social agenda. At the same time, however, I regret that the increased attention paid to citizens' health-related rights has come about solely as a result of a judgment of Court of Justice. I speak as someone who has himself survived cancer and who knows of cases where patients have been told 'there is nothing more we can do for you' in one country and received effective care in another.
Freedom of movement means the ability to choose. The ability to choose leads to greater competition and thus greater quality and possibly also lower costs. I am sure that the directive on patient mobility will enliven Europe and have many positive consequences. Our common goal is health for all. The directive on cross-border healthcare undoubtedly means greater closeness to citizens, who are not interested so much in debates on competences than in the shortest route to health - naturally one which is clearly signposted.
The most successful European policy is policy which citizens feel in their pockets, as was the case with the roaming directive. In the case of the directive on cross-border healthcare, citizens will not feel it directly in their pockets, at least not initially, but they will have greater choice for the same money. And that is not a bad feeling, particularly where health is involved.
Evelyne Gebhardt
(DE) Mr President, Minister, Commissioner, when we talk about a social Europe, we must always put people and their concerns at the forefront. Putting them at the forefront means that we must have a top priority, which is that the health system should provide people with the best possible care locally. That is the number one priority. That is the proviso which must underlie our approach to this directive.
There are, however, many other considerations, for which we also need other solutions, be it because people are travelling or are working in other countries or be it because they have a rare disease or because they will receive better care in another country. This means that there is also a need to remove the obstacles to mobility in such cases and to ensure that legal certainty is created. That is the second priority.
The third priority is that we must remember time and time again that, under the European treaties, healthcare in the Member States is a matter for the Member States, and we must respect that. In other words, the organisation and funding of healthcare systems are the responsibility of the Member States, and our legislation can do nothing to change that. It is not an option, we cannot do it, and we have no intention of doing it unless we were able to agree at some future date to create a common health policy. That would be the ideal scenario, but I am afraid we are still far from ready to take such a step.
Othmar Karas
(DE) Mr President, Commissioner, ladies and gentlemen, we and the people of Europe are pleased that we can finally begin the parliamentary discussion of this proposal.
I regret that the threats the PSE Group made to the Commission last December resulted in a deadlock lasting several months. The proposal is good and provides added value for the people of Europe. We want to see the political creation of cross-border legal certainty, so that individuals no longer have to resort to the Court of Justice to assert their fundamental right to personal freedom of movement.
We are discussing a directive on patient mobility, not on health services. Primary responsibility for the assured delivery, the quality and the funding of health care continues to rest with the Member States. We know, however, that we need more cooperation among the Member States in the field of health care and more cross-border European input in research, in the key area of hospital provision and on the supply side.
This question is the free movement of patients. We are not asking whether health-care systems and high-quality health services can be organised without unwanted side-effects; we are asking how it can be done. We are moving in an area between four poles: patients' rights, protection of the healthcare systems, protection of health insurance schemes and quality assurance with regard to health services, security of funding and legal certainty.
Patients have a legitimate interest in seeking out what seems to be the best health service. To enable them to do so, we need a legislative framework and legal certainty. On the other hand, the great majority of the population want health services as close as possible to their own homes. We have the problem of funding the system of health care in the Member States. More mobility at the same cost is therefore the right way forward. We have the issue of quality assurance with regard to health services. We should launch the debate on European minimum standards in this area too.
Mia De Vits
(NL) Mr President, Commissioner, I share the view of other Members that it is an important achievement to have this proposal on the table at last. It meets a need, a reality on the ground and it means we can really do something for people.
Some members claim that only the well-off will be able to get themselves treated abroad. We must make sure that healthcare abroad is accessible not only to the most affluent, because they are able to use the law to obtain expensive procedures. Patients have a right to clarity and legal certainty and we can work on that, that is our job.
The proposal is a distinct plus for EU citizens. It is not perfect, of course, there are a few improvements to be made. I am thinking of the definitions of 'hospital', 'non-hospital care' and so on and the identification of specific cases where prior authorisation may be warranted. These are things we shall certainly address in the debate.
So I hope our debate will be calm and pragmatic and not an ideologically based debate. Other aspects will need to be dealt with by national legislation, but I absolutely cannot agree with those who say that this proposal undermines the ability of Member States to organise their healthcare. I think it most important that we discuss this proposal.
Milan Gaľa
(SK) Responsibility for the health systems in the Union rests first and foremost with Member States. Responsibility for the organisation and provision of healthcare and medical services in accordance with Article 152 of the Treaty is fully recognised.
The proposal aims to introduce and ensure a transparent framework for the provision of safe, high-quality and effective cross-border healthcare within the Union, at the same time ensuring a high level of health protection while fully respecting the principle of subsidiarity. Although I wholeheartedly approve of the intention and goals set in the directive, I should like to point out certain shortcomings of the proposal that could be overcome.
Some are afraid that this type of care might place the health insurance systems in some Member States under undue pressure. We need a more precise definition of procedures relating to providing care and reimbursement in respect of repeated hospitalisations and damages, as well as treating complications. We must set a time horizon for reimbursement of costs and at the same time clearly state that the directive neither will not wants to solve the long-term healthcare issues in such establishments where the health and social systems usually meet.
The term 'beneficial for the patient' must be specified. The medical aspects should be taken into consideration in the first place, not subjective benefits. When specifying the terms 'hospital care' and 'outpatient care', it would also be good to specify the term 'specialised outpatient healthcare'. In addition to that, the problem of the method of reimbursement of prescriptions issued in other countries still remains.
Ladies and gentlemen, just like on those other occasions when we witnessed the introduction of free movement in the past, certain worries exist. In my opinion, however, they are not insurmountable.
Pier Antonio Panzeri
(IT) Mr President, ladies and gentlemen, it has been said that health services are a major pillar of the European social model. For that reason, it seems entirely right that we should address the issue with a view to ensuring a high level of health protection and equal access to healthcare for all; unfortunately, the text under discussion does not seem to be moving in that direction.
We need to avoid striking at the roots of the purpose for which the directive should be issued, and that is to guarantee, within the framework of free movement, the right of citizens to take advantage of health services within the Union. In practice, the text can be seen as an instrument geared towards opening up the health market at Community level, something which is quite different and could well lead to a right to health for the well-off.
The text provides solely for the reimbursement of the costs paid by them and only the cost of the health service as compared with the cost in the country of origin, disregarding the costs of travelling to and staying in the host country. Further critical points have also been discussed, ranging from the need to guarantee standards of service at Community level to the important issue of information.
For those reasons, I consider that more detailed thought is needed so that we can try together to provide European citizens with the answers that are still lacking in the directive itself.
Roberta Alma Anastase
(RO) First of all, I would like to welcome the entire proposal made by the Commission regarding a new social package. The necessity of modernising the European social model is obvious in the specific context of the 21st century and of the objectives sought in the Lisbon Strategy concerning sustained economic growth and the prosperity of the population.
The directive currently under debate is important in the enforcement of the renewed social agenda, particularly in the context of priorities related to the promotion of geographic and professional mobility, as well as to a longer and healthier life of European citizens. I hope that the provisions of the directive will bring healthcare services closer to home, and I am referring to all social categories, including emigrants, people working abroad and undergraduates studying abroad.
It is essential that healthcare should provide secure, quality services, no matter where in Europe it is provided. In this regard, I would like to stress the importance of education and training of European professionals in the field, as well as the importance of facilitating European communication and the exchange of good practice. Given the crossborder nature of the directive, professional training should include knowledge of foreign languages and familiarity with the fundamentals of intercultural dialogue.
Not least, adequate knowledge of information and communication technology is just as necessary for the success of the directive; moreover, it is crucial in strengthening the so-called field of e-health.
Daciana Octavia Sârbu
(RO) The provision of healthcare services is a pillar of the European social model, and the creation of an internal market for these services should not encourage medical tourism, which will be available only to well-off patients who can speak many foreign languages and have access to information.
What is required is a clarification of the conditions for the reimbursement and licensing of healthcare, as well as a clarification of the concept of healthcare. I am concerned about the effects that this directive will have on the new Member States. European citizens will not travel to countries where healthcare is very expensive; on the contrary, they will go to countries such as Romania, Bulgaria, or Poland, leading to an exodus of patients from Western Europe to Eastern Europe.
Although healthcare provision in the new Member States in accordance with clearly defined standards of quality and security does not apply uniformly to all types of healthcare, the demand for dental services in Eastern Europe is constantly increasing. This will cause prices to soar in the host countries, rendering their citizens' access to healthcare more difficult, owing both to high prices and to the fact that certain companies will look for customers willing to pay more.
Opening up the European market in healthcare services will have a severe impact on the healthcare system in Eastern Europe, leading to inequality. Increased freedom of choice in the manner and location of healthcare provision is a positive thing, as long as all citizens have access to services, irrespective of their social standing.
Dariusz Rosati
(PL) Mr President, the aim of the social package should be to guarantee universal and equal access to high quality healthcare services to all EU citizens. To a certain extent, this objective can be reached by appropriate regulation at European Union level, but there are many problems that result from mistaken and ineffective solutions at the level of individual Member States. For this reason, the Commission should encourage Member States to reform their national healthcare systems, primarily through spreading good practice and through effective financing methods.
A precondition for effective healthcare is the free movement of medical personnel between Member States. In this context I must draw your attention to the restrictions that continue to apply to Polish nurses and midwives wishing to work abroad. This is discrimination against Polish workers and is a blatant breach of the principle of free movement of labour and the principle of equal treatment. I call on the Commission to put an end to these discriminatory practices and to give back to Polish nurses the right to carry out their profession, without restrictions, in other European Union countries.
Zita Pleštinská
(SK) The Committee on Internal Market and Consumer Protection held intensive discussions about the provision of cross-border healthcare back when the Services Directive was debated. The agreed compromise was reached only because healthcare services were excluded from the scope of the Directive due to their specific nature. Since this is a complex problem, I welcome this debate.
Clear and understandable information must be available to the patient even before he requests healthcare in another EU Member State, in particular regarding the level of treatment costs, the possibility of being reimbursed by his health insurer and the need for prior authorisation. Ladies and gentlemen, we have to adopt rules at European level that will enable the patient to make use of healthcare services anywhere within the EU, rather than make him a victim of the system.
Arlene McCarthy
Mr President, many speakers stress the fact that all patients, whether they travel or stay at home, are entitled to high-quality, safe health care. Let us not forget that one of the biggest demographic challenges we have is an ageing population who will inevitably want health care in their own locality. So we need clarity to respect the right of patients to access health services, and at the same time we need to respect the Treaty provision stating that the organisation of health services, especially financing, is a competence of the Member States. We must recognise that 27 states have different systems, different funding systems. I regret that the directive is not clear on this point, but I have confidence that our rapporteurs can clarify these issues: if we want to keep out the lawyers we must have clarity, not just to avoid patients going to court, but to avoid them going to court on cross-border medical negligence issues.
So we need to have more innovation in our approach. The ideal mix, I believe, is to have patient mobility and to encourage Member States to buy in expert services, not just to treat one patient but to treat groups suffering from the same condition. This could be more cost-efficient, and could enable patients to stay close to family and friends.
Marios Matsakis
Mr President, this directive is wonderful in theory, but it could turn out to be a nightmare in practice. I say this because it could lead to services getting better in some centres but worse in others. I will give you an example: if patients from a small country like Cyprus with a neurosurgical problem all go to Sweden or Britain to have their neurosurgical treatment, then what will happen to the neurosurgical services in Cyprus? The standards will diminish, inevitably, and this holds for cardiovascular services, for orthopaedic services, for oncological services and for many others. So we must be very careful.
I fully support this directive, but we must make sure that we do not make good centres better and bad centres worse. We must be careful to raise the health standards right across Europe, in large countries as well as in small countries.
Czesław Adam Siekierski
(PL) Mr President, the purpose of the new social agenda is, among other things, to reduce barriers to mobility in a society that accepts the principle of equality, where there should not be any barriers in anyone's way. A very important issue here is the proposal relating to the directive concerning the rights of patients in cross-border healthcare. This is needed for people to be able to function in today's fast-moving world, where people travel hundreds of kilometres to attend a specific meeting. For this reason it is very important that every European should know that if their lives are in danger, someone will save their life and safeguard their health without unnecessary regulations or other obstacles. We should make sure that every inhabitant of the EU knows that, in order to be able to access healthcare in an emergency, they must have a European Health Insurance Card. Patients must know that, in an emergency, they should be treated on the same basis as the citizens of the country where they are being treated. Quality, productivity and, above all, the safety of patients are the issues that, for us, should be the most important.
Christel Schaldemose
(DA) Mr President, I should like to thank the Commission for presenting this Directive. I think it incredibly important that politicians have the opportunity to discuss patient rights, rather than it being left to the European Court of Justice to take decisions in such an important area. In my view, patients are of supreme importance. We must put the spotlight on patients, but for this reason we must also reflect on how to orient this Directive, so that the spotlight is on giving all patients the opportunity to receive good treatment. Therefore, I believe it is important to ensure that the Directive enables patients staying at home in their own Member State to have access to proper treatment too. Thus I believe that this prior authorisation should be the rule rather than the exception.
This is what I believe we need to focus on. In addition, I would agree with my colleague Mrs Sârbu in what she said about the need for us to take care that this Directive does not create a divide between east and west, north and south in Europe.
Colm Burke
Mr President, I welcome the proposal from the Commission. The question that is being asked is 'What can Europe do for me?'. I think it is important that we make health care available if it is not available in the home country. As one of the people who has benefited from cross-border health care - but I could afford it - it is important that it is available to everyone right across the Community. However, the issue that arises is that there should not be a delay in making sure that treatment is available. That is one of the things that I think is important in developing this policy.
Proinsias De Rossa
Mr President, I believe there are a number of principles that have to be addressed in this issue. The first is that patients' health obviously has to be at the heart of it.
We must not leave the issue of these rights to decision by the courts. We as lawmakers must make the law in this area.
Thirdly, competition must not be encouraged, or be the outcome of this directive, between national health services; nor indeed should competition generally be encouraged in this area.
Petru Filip
(RO) The new Member States are facing a significant level of migration of highly skilled workers in the health services sector, a phenomenon which is leading to severe imbalances, correction of which will require a significant financial outlay. It is necessary that the new Member States benefit from extended European funding programmes to develop flexible healthcare provision for all patients, in a concrete, non-discriminatory manner.
Monica Maria Iacob-Ridzi
(RO) European mobility policy is one of the most important EU policies, allowing all citizens to establish themselves and work in those countries where they can benefit from an improved standard of living. However, free movement is significantly hampered by concerns about the possibility of recouping the cost of medical treatment abroad.
Therefore, I move for the creation of a European health insurance scheme, recognised by all Member States, facilitating European cooperation in the field of crossborder healthcare. This will lead to the development of a modern social agenda which will contribute to fostering opportunities in the field of education and employment.
Elisabeth Morin
(FR) Mr President, this proposal for a directive is concerned with the interest of patients and it is that human approach on the part of the Commissioner and the Minister that I welcome. I also appreciate the improved cooperation between Member States in terms of respect for national health systems and I hope this opportunity for Europeans will be enhanced by the provision of proper information, which is something they need. Effectiveness and humanity: that is what pleases me in this proposal for a directive.
Panayotis Demetriou
(EL) Mr President, I am proud that this directive has been created and promoted by two Cypriot Commissioners, Mr Kyprianou and Mrs Vassiliou. The directive is correct and necessary, and must be implemented.
The main focus of this directive is the patient, who is entitled to the best possible medical care, particularly when it cannot be provided in the patient's own country.
The practical difficulties have been correctly identified and need attention, because bad practice may end up nullifying an idea that is sound in other respects.
Roselyne Bachelot-Narquin
President-in-Office of the Council. - (FR) Mr President, Commissioner, ladies and gentlemen, let me start with a few personal comments and say how happy I was to meet up again with my colleagues from the Committee on Employment and Social Affairs, Mr Andersson, its chairman, Anne Van Lancker, Ria Oomen-Ruijten, Jiří Maštálka and others. May I offer them my warmest greetings.
John Bowis, speaking on behalf of the PPE, put the issue in its proper context by asking: 'What does Europe do for me?' He reintroduced the question of a neighbourhood Europe, followed by numerous others such as Dagmar Roth-Behrendt on behalf of the Socialist Party and Jules Maaten for the ALDE Group.
Many of those who spoke after John Bowis also emphasised that patients take precedence over states and systems. That is very true. Yet we must not end up by opposing patients, states and health insurance systems because any destabilisation of health insurance systems would have dreadful repercussions on the organisation of healthcare and, specifically, on the patients we want to protect.
That is why I would reply to Dagmar Roth-Behrendt that the question is not of patients' right of movement within the European Union, which is a self-evident, fundamental right. The question the directive raises is of reimbursement and reimbursement terms, of the right or not to reimbursement. Article 152 of the Treaty makes it clear that Member States are free to organise and finance the healthcare they provide as they wish.
At the heart of the issue of prior authorisation lies the question of balance, of the soundness of the accounts of the national health support and insurance systems, especially those of the poorest states. This text reminds us of that responsibility and under no circumstances can states use this directive as a means of evading those responsibilities.
Basically, Jean Lambert was saying that cross-border care is not a goal in itself and Derek Roland Clark pointed out that perhaps we should make sure the provisions of the new directive did not ultimately benefit only a few of the wealthiest, most educated and best informed patients while the poorest patients would, of course, be treated unfairly.
The key question here, however, the question under debate, which the Commission and the Council should look at in depth, is prior authorisation for hospital care because that is indeed where there is the greatest risk of deregulation of national systems.
Jean Lambert asked whether the proposal for a directive was compatible with the regulation on social security coordination. The Court has found that those two reimbursement systems were compatible. We must ensure, therefore, that the two systems are properly structured. The proposal for a directive before us gives priority to implementing the regulation, which seems reasonable. Yet the principle of the patient's freedom of choice must continue to apply if, for any reason other than financial, a patient prefers to go down the road opened by ECJ case law.
Like Bernadette Vergnaud, some MEPs regretted the fact that this text does not cover all the difficulties encountered by patients within the EU, and more specifically in their country of origin. When you look at the difficulties to be resolved by this text alone, you can see that it was unlikely that proposing a wider-ranging text would have been the best way of making progress in terms of resolving certain very practical problems, such as reimbursing healthcare for patients moving to another European country for the purpose of study, work or simply holidays.
Similarly, this is not just a directive on health services, to be regretted or welcomed. So it serves no useful purpose to decry it as some kind of 'Bolkestein directive'. That really is not what this directive is about.
Once its basic principles have been established - and I have noted them - this directive must therefore enable us to preserve a certain means of regulation, as it already exists between the Commission and the Council but also between many MEPs on all benches, in regard to respect for these options open to patients. As regards prior authorisation for cross-border healthcare, Member States must remain responsible for deciding on the range of care they offer.
It is also important that when a state imposes certain conditions of access to care for public health reasons - such as the doctor's referral system or what is known as gate-keeping in English - its systems are respected and applied when patients turn to a health system in a country other than their own.
Obviously, this discussion on the directive cannot be dissociated from the Commission's forthcoming communication or from the Council's proposal for a recommendation on Community action in the field of rare diseases. I believe it is entirely possible to hold those discussions at the same time. Another issue that many MEPs raised was the interoperability of health information systems. This directive may contribute to that in legislative terms.
Commissioner, ladies and gentlemen, of course we are only at the start of this dialogue, of the discussion on this subject, which will have to cover such vast areas as data protection, transparent enacting terms and perimeters. Here again, however, with the directive creating legal certainty, we should be able to advance along the road of interoperability, which does not mean going it alone but, quite simply, harmonisation and greater compatibility.
Thank you all for your deep and meaningful contributions, which have shed great light on our debate.
Androula Vassiliou
Member of the Commission. - Mr President, this has been a very interesting discussion.
Let me say that very often we hear the question: how can we bring the citizen nearer to the European Union?
This is one example of how we can make the citizen feel that the European Union is doing something for him or her. Under the present system, there are many inequalities. With the clear legal framework provided by the draft directive concerning citizens and the various issues we are trying to give clear information to the citizen about their rights and how they can exercise them.
It is true that there are concerns. I listened very carefully to your concerns, and I am sure that during the course of the debate and the deliberations we shall have, we have to address these concerns so that the end result will be something which is really of benefit to the citizen.
This is not a Bolkestein Directive II - far from it - and we should never think that this is so. It is about patients' rights and how to exercise those rights.
We are not trying to harmonise health systems. Member States can continue to exercise and regulate their health systems, and they can decide for themselves what benefits they want to offer to their citizens, and to what extent.
We are not trying to encourage health tourism. We are not trying to give citizens the chance to have their faces and their bodies fixed; rather, we are trying to give citizens the right to have proper health care when they are sick and they need it.
Nor do we expect a big exodus of European citizens from their home state to another Member State. According to the calculations and to the impact assessment that we have, only a very small percentage of citizens wish to go abroad. Why? Because they want to have the care that they need nearer to their families, they want to speak their own language and to be in a familiar environment.
However, there are cases when they need some extra health care which their home state cannot provide. This is a right that we give them - this extra right to have an informed choice and decide for themselves where they go for their health treatment.
Indeed, we have had encouragement from the European Court of Justice to legislate. We cannot leave it all the time to the Court to decide about the rights of the patient case by case. This is not just. How many European citizens can afford a lawyer and can afford to go to court? Only a very few. Therefore, we must offer solutions to all the patients, give them the right information and let them decide for themselves what they need.
This is a time for all of us to work together - the Council, the Commission and Members of Parliament - to find the best possible solutions for patients.
(Applause)
President
Thank you, Commissioner, I think the applause in the Chamber reflect Parliament's satisfaction.
I have received, pursuant to Rule 103(2) of the Rules of Procedure, six motions for resolution winding up this debate.
I would inform you that the EPP-ED Group has now withdrawn its motion for a resolution.
The debate is closed.
The vote will take place in a few minutes' time.
Written statements (Rule 142)
Lívia Járóka  
in writing. - Healthcare for Roma has been systematically denied or rarely taken into consideration across Europe, despite the fact that access to healthcare is a fundamental right for European citizens. The Renewed Social Agenda on cross-border healthcare must address the problems Roma encounter in their failure to have healthcare services within a short distance of their community. Most Roma live on the periphery of urban centres, and miles away from health facilities. Their segregation from these services results in the life expectancy of Roma being estimated at 10 years less than the national average. The prevention of and vaccination against diseases prevalent in Roma communities as well as the question of emergency situations and regular health checks have yet to be resolved. Another factor limiting the access of Roma to healthcare stems from their lack of identity cards, which would enable them to apply for insurance or social assistance. With the fall of the communist regimes, many Roma were not acknowledged, or were forgotten or erased from country citizenship records. Lastly, the health of Roma women must be addressed, as they are the caretakers of the Roma community. If the Commission is to help Europeans obtain healthcare services within the EU, they must ensure this is universally and equally applied.
Lasse Lehtinen  
in writing. - (FI) In a properly functioning Europe, the patient must be able to apply for proper care and treatment wherever it is available. If there are waiting lists for a heart operation or a hip replacement in one country, access to treatment in another country must be possible without any protectionist jungle of legislation. The removal of barriers also means better use of existing resources. Most of the speeches opposing the movement of patients and services appeal to the worst aspects of Europeanness, xenophobia and mistrust. Properly functioning health services, both public and private, are part of the welfare society - the European welfare society.
James Nicholson  
in writing. - Cross-border healthcare is a key element of the social package. While the EU has facilitated freedom of movement and the right to live and work in other EU countries, clarification regarding patients' rights to access healthcare in other Member States was urgently required.
Despite numerous European Court of Justice rulings on this subject, citizens are not fully aware of their rights on this issue. Moreover, they are not adequately informed about their exact entitlements, how to go about arranging treatment, or indeed reimbursements.
In Northern Ireland, projects have been piloted around the border counties which ensure that people can benefit from the most appropriately located healthcare services. These projects have been very successful and have been very much appreciated by the people who have benefited from them. In this regard, I would like commend the British Medical Association (NI) and the Irish Medical Association for their efforts in promoting cross-border healthcare between Northern Ireland and the Republic of Ireland.
While I welcome this work by the Commission, I cannot help feeling that it is overdue. Now that this issue has been clarified and given a legal framework, I sincerely hope that Member States will fully cooperate.
Marianne Thyssen  
in writing. - (NL) We are still glad that the European Parliament excluded heath care services from the general directive on services. Healthcare is after all a specific sector requiring a specific approach.
The fundamental premise of the proposal, in line with established case-law, has to be that the organisation and funding of healthcare are the responsibility of Member States. This means on the one hand that patient mobility cannot be made an absolute right and on the other hand that there are no excuses for not investing in one's own health system. That premise also necessarily implies that Member States must be able to charge the real cost to the patient. There must be solidarity, but there must also be the possibility of differential treatment for patients who have contributed in their own country through the social security and tax system and foreign patients who have not.
The fact that we have the directive is a good thing, but anyone familiar with the sector feels that it still needs a lot more work. To my mind the quality, accessibility and financial sustainability of healthcare on the basis of socially responsible solidarity remain the key criteria here.
Silvia-Adriana Ţicău  
in writing. - (RO) I believe that access to quality healthcare is one of the essential values of a Social Europe. Patients' rights within the EU and crossborder cooperation in this field among the Member States constitute a significant part of the new social package. Patients must have access to quality health services in any Member State and they must have the possibility of being reimbursed with amounts that are equal to the amount they would receive in their own country. Today there are significant differences within the EU as regards both the quality of health services and the reimbursable amounts. I believe that an assessment of the European health system and of the medical technology in use is required as a matter of urgency. The appropriate equipment of all hospitals with the technology required to diagnose and treat various conditions is a prerequisite for the provision of quality healthcare. Physicians and nurses move from one Member State to another both in search of better wages and due to the availability of better diagnostic and treatment facilities. It is important that the directive on the patients' rights include, according to EU priorities, a minimal list of health services which should be fully covered by health insurance budgets.
