The problem of cross-border healthcare

The EU will in January publish its long-awaited directive on access to cross-border health services in a bid to provide more certainty about patients’ rights to use services in another EU country, writes Jennifer Rankin.

When the Treaty of Rome was signed 50 years ago, the concept of patients’ rights did not mean very much. The predominant attitude was ‘wait your turn and be grateful’. Half a century later, all European health systems are finding that they must catch up with the demands of a better educated, less deferential public, increasingly aware of its rights.

That public is more prone to travel, work or live beyond national borders, posing cross-border problems about healthcare. Increasingly too, public health issues go beyond national borders. The European Commission has turned its attention to healthcare, perhaps because it is trying to get more in tune with public opinion, perhaps because it is trying to extend its remit. "There is clearly a growing demand for the EU to act on health," claimed Markos Kyprianou, the health commissioner, in a speech in October. But although the Commission has some big ambitions for health, it has limited competence.

National governments get edgy when the EU looks at health. In 2005, the Commission was forced to remove healthcare from the scope of the directive on services. Nevertheless, a small but significant body of case law has pushed the EU towards firmer policies on health services. In June 2006 ministers from the then 25 EU states asserted that "we strongly believe that developments in this area should result from political consensus, and not solely from case law".

The upshot of this tension is the directive on access to cross-border healthcare, which was initially meant to be presented yesterday (19 December), but will only be published January. Early drafts show that the directive will be a carefully calibrated effort to ensure clarity for citizens and healthcare providers about what patients are entitled to, without infringing on the competences of national governments.

But this will not be enough to satisfy some critics. On 10 December, 48 MPs from the UK’s governing Labour party signed a parliamentary motion condemning the directive for its potential to "undermine the fundamental principles of the NHS [National Health System], impose unnecessary burdens of cost and bureaucracy, over-rule clinical priorities and act to worsen health inequalities".

Jules Maaten, a Dutch Liberal MEP who served as the European Parliament’s co-rapporteur on the consequences of excluding health from the services directive, rejects the allegation that the directive would be "harmonisation through the backdoor", arguing that the current system is haphazard and badly arranged.

Patients and groups that represent them seem to be enthusiastic about the idea behind the directive. Judy Birch, a British national who travelled to France for an operation, says that "patients should be able to have the expertise that exists elsewhere".

"At the moment, patients are not told what their options are and are not referred," she says.

After her experience Birch set up a patients’ group for people with chronic pain to raise awareness of access to treatment. Nicola Bedlington, director of the European Patients’ Forum, thinks the directive "should move towards a highest common-denominator in terms of quality of health services". "But I don’t see it as a universal harmonised health system across the EU - that is politically and legally not possible," she adds. But both Maaten and Bedlington admit that there is a risk that increased access to cross-border healthcare could deepen inequalities of access within member states. Although they both say that widening health inequalities constitute a general trend across the Union.

More patient mobility could put over-stretched budgets under more pressure. According to Commission estimates, cross-border healthcare represents 1% of public expenditure on healthcare (€9.7 billion). Currently member states do not seem too worried on this score: "It is not going to drive up costs hugely," says a UK official. But it could become a problematic issue for new member states, where health services are on a tighter budget.

The right to cross borders for healthcare raises some tricky issues for all countries. But it cannot be undone: there is no going back to a time when people were less mobile and less demanding. The already difficult act of balancing the competing pressures of meeting public demands, reducing inequalities and keeping services affordable will only get harder.

The EU will in January publish its long-awaited directive on access to cross-border health services in a bid to provide more certainty about patients’ rights to use services in another EU country, writes Jennifer Rankin.