National health barriers under the Union’s scalpel

Date: 13/01/05

Attempts by the European Commission to dismantle barriers to a single EU market in services are becoming a testing ground for healthcare policy. National governments are worried about the public spending implications and about losing control over their citizens' healthcare. Peter Chapman reports EU citizens would be limping across national borders for routine health treatment, under plans put forward last year by Frits Bolkestein, the then commissioner for the single market.

The proposals on healthcare are among the most controversial in the Dutchman's blueprint to dismantle barriers to a single market in services across the Union. They would allow patients to go abroad for most types of care not requiring an overnight stay in hospital, without having first to acquire prior authorisation from their national authorities.

Patients would be able to get their medical charges reimbursed by their national health systems at the same level as they would get at home, without the inconvenience, and pain, of waiting for appointments.

Treatment for minor ailments such as in-growing toenails or wisdom teeth would enable patients to shop around for faster, more convenient, or better care in recognised clinics, surgeries or hospitals in other countries.

Those suffering from more serious conditions would also be able to seek out specialists with knowledge or expertise that might be scarce or non-existent in their own state.

In theory, the system could bolster the single market by rewarding efficient service providers with more cross-border customers.

At the same time it would increase the scope for smaller countries to rationalise their systems without having to duplicate facilities in bigger or richer member states.

It would also provide an incentive for specific hospitals to specialise in certain types of care.

Changes to the rules governing so-called 'non-hospital' care are the key healthcare innovation in the services directive.

But the Commission is also seeking to clarify the consequences of rulings in the European Court of Justice concerning less routine types of health care and the free movement of patients.

These concern the complex relationship between member states about who pays what to whom when citizens of one EU country use healthcare services in another member state, for example for lengthy stays in hospital.

Under the terms of a regulation dating back to 1971, national authorities are responsible for issuing authorisations for their citizens to go to another country.

The court has stated that they cannot deny authorisation in cases where the citizens would be forced to wait too long at home for care, such as a hip replacement, ordinarily offered by their home health system.

But Commission experts complain that some member states are reluctant to implement the rulings - or the rules are applied in an ad-hoc and conflicting fashion.

"We know of one case where two sisters living close to a border had the same condition," explained a Commission expert. "But only one of them was granted authorisation to seek treatment in the neighboring country. That is because their applications were seen by two different officials."

The Commission believes that the proposals add value for patients, without robbing member states of control over their complex health systems and crucially, their healthcare budgets.

Nevertheless, some of the more sceptical governments have demanded safeguards be written into the text of the directive to make sure they are not offering savvy patients a blank cheque.

For example they want to retain control over what types of 'non-hospital care' can be treated without prior authorisation.

EU citizens would be limping across national borders for routine health treatment, under plans put forward last year by Frits Bolkestein, the then commissioner for the single market.

Many countries want to ensure that they only have to pay the bill for care that their own health service would normally cover - and not more lavish services that might be the norm in richer states.

The Dutch, while holding the presidency of the EU's Council of Ministers, presented a number of amendments to Article 23 of the draft directive, which covers healthcare, in order to make clearer what patients could and could not expect.

The Luxembourg presidency must continue the work. A final agreement on the directive is expected in the second half of the year under the UK presidency. The dilemma for the British is that while they are staunch supporters of the services directive, they are opposed to some of the healthcare elements, largely because of their funding consequences.

Just as intriguing for the forthcoming legislative struggle will be the position of Bolkestein's successor Charlie McCreevy. The commissioner responsible for driving the legislation through is a former finance minister of Ireland and might be expected to be sensitive to complaints from national treasuries about possible funding difficulties thrown up by the healthcare provisions.

But as MEPs prepare for a first reading of the proposal, aides to McCreevy say that misconceptions about the scope of the directive abound.

Some, they say, are propagated mischievously by people wishing to derail the opening of EU healthcare markets.

One oft-cited argument is that the law would allow groups of private hospitals to escape strict controls by setting up their head offices in a member state where regulations are the least restrictive.

According to the scare-mongers, all the hospitals operated by that company would be regulated according to the rules in place in the country where the head office is located.

Sir Sandy Macara, a member of the British Medical Association, warned in European Voice last November that: "If these regulations are subsumed by the internal market, supervision of professional practice from the 'country of origin' rather than the host country would be so difficult as to be meaningless."

He added: "Unscrupulous practitioners would be able to establish themselves in a poorly regulated country and work in a highly regulated one, free to ignore the rules that exist to guarantee patient safety in the host state."

But McCreevy's team say this is simply not true - and that each hospital, clinic or healthcare centre is treated as an individual enterprise and is thus subject to the full force of any rules and regulations in the member state where it is based.

Macara argued that: "Health is not a service like any other."

The coming months will decide whether healthcare should be given special treatment.

Controversial issues at stake

Across a range of healthcare issues, the divisions of responsibility between national governments and the EU are being tested.

Should the goal of a single EU market in services be used to break down barriers between national health services? Should national governments be allowed to maintain different rules on the reimbursement of drugs? What powers should the EU assume to combat trans-national threats to public health such as disease epidemics? To what extent should the EU set the healthcare agenda of national governments?

These controversies are heightened by worries about the effects of EU decisions on healthcare on public spending, at a time when national budgets are under severe pressure. The coming months will see a series of crucial arguments over healthcare in Europe.

Article reports on the controversy surrounding the EU's plans for the healthcare sector as part of the move towards a single market in services across the Union.