EN Official Journal of the European Union C 120/54

Opinion of the European Economic and Social Committee on the ‘Communication from the Commission: Follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union’

(COM(2004) 301 final)

(2005/C 120/11)

Procedure

On 20 April 2004 the Commission decided to consult the European Economic and Social Committee, under Article 262 of the Treaty establishing the European Community, on the abovementioned communication.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 22 September 2004. The rapporteur was Mr Bedossa.

At its 412th plenary session on 27 and 28 October 2004 (meeting of 27 October), the European Economic and Social Committee adopted the following opinion by 170 votes to 3, with 6 abstentions.

1. Introduction

Health systems and policies in the EU Member States are becoming increasingly interconnected; and when national authorities engage in benchmarking against existing systems, European or non-European, before taking decisions, they do so inadequately and unfortunately without pointing this out.

1.1 There are many interrelated reasons for these trends. — firstly, the expectations of the general public are increasing across, and also beyond, Europe; — the recent enlargement of the European Union is going to oblige the new members to provide their citizens with increasingly modern health systems; — major technological innovations are introducing new therapeutic practices and approaches which are making it possible to provide an improving quality of care; — new information techniques available to EU citizens are enabling them to make almost instant comparisons of diagnostic procedures and healthcare provision in the different countries of the European Union, which for respectable and understandable reasons may result in pressure on resources to achieve optimum results.

1.2 This will necessarily cause problems in health policy, whether with respect to the quality or accessibility of cross-border healthcare, or to the information needs of patients, health professionals and policy-makers.

1.3 These factors are already making it necessary to evaluate national policies, which must take all these needs into account, in the light of European commitments that are gradually growing and giving new rights to Europe's citizens.

1.4 This new situation now guides the debate between those who maintain that this freedom of choice will produce a harmful destabilisation of current healthcare systems, on the grounds that limiting patient mobility makes it easier to control systems in terms of cost or priorities, and those who advocate patient mobility because it allows interoperability of systems, use of the same indicators, exchange of best practice and a more intelligent pooling of resources. The aim should no doubt be to follow the second school of thought, whilst drawing all the requisite conclusions in terms of harmonising national systems.

2. Background

2.1 In its own-initiative opinion of 16 July 2003 (1), the European Economic and Social Committee defined health as ‘a fundamental asset for society’, which ‘is equally applicable to each individual citizen, family, and nation’. The Committee concluded that it ‘intends to make healthcare issues an area for action, whilst respecting the existing Community political and legal framework.’

2.2 In that opinion, the European Economic and Social Committee put forward arguments and proposed work approaches and methods of analysis which have been taken up in two recent communications of the European Commission (of 20 April 2004) addressed to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions.

2.3 The communication in question was needed because of the recent publication (on 9 February) of the latest proposal for a Directive on services. Unfortunately, its treatment of social and health services provoked much criticism because the wording is too open to interpretation. Therefore more precise definitions are required in these sections of the directive so that adequate account is taken of the special nature of these services, which has to do with citizens' safety and equal treatment.

2.4 The Commission also published the two communications concomitantly because, starting with the Kohll ruling on 28 April 1998 and continuing through to the Leichtle ruling on 18 March 2004, the Court of Justice has established a whole body of case law that now allows European Union citizens to use healthcare facilities in other countries of the Union, as well as clarifying the conditions for reimbursing the costs of healthcare.

2.5 Since 1 June 2004, Europe's citizens can prove their entitlement with a future European health-insurance card (2), which replaces the E111 form.

2.6 The different healthcare conditions and environments in different EU countries may encourage people to seek the most effective systems, producing sudden bottlenecks or incapacitating European centres of reference. There is also a risk of exploiting social protection systems, which are unable to respond to erratic movements of patients from other countries. In this context, the new Regulation 1408/71 might contribute to creating new and problematic situations.

2.7 The challenge is therefore to develop a European policy that allows the most constructive goals to be set, even if this entails modifying the prerogatives of national healthcare systems where absolutely necessary.

2.8 A close look at the own-initiative opinion adopted by the European Economic and Social Committee on 16 July 2003 shows that it covers much the same ground as the high level reflection process initiated by the European Commission, and the points covered in its recommendations are raised and analysed in this draft opinion: European cooperation, information for patients, professionals and policy-makers, access to high-quality care, reconciling national health policies with European obligations, etc.

3. General comments

3.1 The communication on patient mobility contains a set of concrete proposals covering many areas. Thanks to these proposals the Treaty's objective of ensuring a high level of human health protection will be able to be incorporated into Community policy.

3.2 Community law entitles citizens to seek healthcare in other Member States and receive reimbursement. Court of Justice case law and the proposal for a directive on services in the internal market effectively clarify the terms of reimbursement for healthcare provided in a Member State other than that in which the patient is insured. However, in practice it is often not always easy to exercise these rights.

3.3 It therefore seems necessary to develop a European strategy to:

3.3.1 promote European cooperation to allow better use of resources: — rights and duties of patients: the European Commission will take measures to explore further the possibility of reaching a common understanding of patients' rights and duties, both individual and social, at European level; — sharing spare capacity and trans-national healthcare: the European Commission will provide funding for evaluation of existing cross-border healthcare projects, in particular Euregio, and will consider how to promote networking between those projects with a view to sharing best practice.

3.3.2 In order to establish a clear and transparent framework for the purchase of healthcare, which the relevant authorities of the Member States would be able to use when entering into agreements with each other, the European Commission will ask them to provide information on existing arrangements and will present appropriate proposals. — Health professionals: the European Commission calls on the Member States to provide up-to-date and complete statistics on the movement of health professionals through the structures governing recognition of professional qualifications. The Commission will also continue work with the Council and Parliament to ensure simple and transparent recognition procedures. — The Commission will also continue preparatory work with the Member States to ensure sufficiently confidential exchange of information on the free movement of health professionals. — The Commission will ask Member States to consider issues related to current and future shortages of health professionals in the Union. — European centres of reference: the European Commission will issue a call for tender under the public health programme in order to draw up a list of reference centres, before making proposals. — Health technology assessment: the Commission will introduce a coordinating mechanism for the evaluation of health technologies, and will present separate specific proposals to this end.

3.3.3 Meeting the information requirements of patients, professionals and policy-makers: — health systems information strategy: the European Commission will develop a framework for health information at Union level based on the results of the public health programme, by identifying the different information needs of policy-makers, patients and professionals, and the means of providing information, taking account of work done in this area by the World Health Organisation and the Organisation for Economic Cooperation and Development; — motivation for and scope of cross-border care: with the aim of establishing the reasons which prompt patients to seek healthcare in other countries, together with the specialist areas concerned and the nature of bilateral agreements, etc., the European Commission plans to carry out a specific study as part of the public health programme. This issue will also be addressed in the ‘Europe for patients’ research project; — data protection: the European Commission will collaborate with Member States and national data protection authorities in order to raise awareness of the data protection rules relating to healthcare; — e-health: having been asked to consider establishing European principles on the competence and responsibilities of all those involved in providing e-health services, the European Commission will address this question in the context of its overall action plan for e-health, as set out in the Communication on E-health – making healthcare better for European citizens: an action plan for a European e-health area.

3.3.4 Strengthening the Union's role in achieving healthcare objectives: — improving the integration of health objectives into all European policies and activities: the European Commission will collaborate with the Member States to gather information on how the various routes of access to healthcare in other Member States operate in their country, and on their impact, especially with respect to access routes arising from European rules; — the Commission will also build on ongoing projects regarding health impact assessment to ensure that the effects of future Commission proposals on health and healthcare are taken into account in their overall assessment; — establishing a mechanism to support cooperation on health services and medical care: in response to a request to establish a permanent mechanism at EU level to support European cooperation in the field of health care and to monitor the impact of the EU on health systems, the European Commission has set up a High Level Group on Health Services and Medical Care.

3.3.5 Responding to enlargement by expanding investment in health and health infrastructure.

3.3.5.1 The reflection process invited the Commission, the Member States and the acceding countries to consider how to facilitate the inclusion of investment in health, health infrastructure development and skills development as priority areas for funding under existing Community financial instruments, in particular in Objective 1 areas. In fact, the Union already supports investment in health in the existing Member States, where this has been identified as a priority by the countries and regions concerned. Taking forward this recommendation therefore depends on the regions and countries concerned identifying investment in health and health infrastructure as a priority for European support. The Commission will work with the Member States through the High Level Group on Health Services and Medical Care and through the appropriate structures for the financial instruments concerned to ensure that health is given the necessary weight in the development of overall plans. The need for European investment in health infrastructure should also be addressed in connection with developing the new financial perspectives for the Union from 2006.

4. Specific comments

4.1 The free movement of patients in the Member States raises several issues whose implications must be estimated, evaluated, analysed and taken into account. The first of these is to fully understand the various existing social protection systems, and ideally this means enumerating the criteria governing their establishment as part of a dynamic process, i.e. in the light of current and future trends.

4.2 Prevention is undoubtedly a priority objective, since it can and must make it possible to achieve appreciable savings, and is the best way to approach health policy; the value of good preventive policies with respect to traffic accidents, the spread of AIDS or tobacco use is obvious. The overall impact of prevention in these areas is very impressive.

4.3 To this admittedly incomplete list can be added preventive policies that are currently attracting the attention of all stakeholders - health professionals, the media and political decision-makers - and concern abuse of intoxicants (drugs, alcohol, medicines), promotion of healthy lifestyles (exercise, nutrition, rest), accidents in the workplace and occupational diseases, etc.

4.4 Evaluating these individual, social and family risk factors gives an indication of the incidence of premature avoidable deaths and the associated costs.

4.5 Technological progress in the sphere of medicines or investigative techniques must lead to effective replacement of old techniques by new ones.

4.6 Above all, greater efficiency must be achieved, even if social, cultural and/or corporate interests act as a constraint on necessary changes. In the final analysis, this is more economical for society as a whole.

4.6.1 The idea should be to encourage the search for more specific and more effective measures, which must stimulate initiatives by socio-occupational stakeholders to improve common health policies.

4.7 If patient mobility has been correctly anticipated, the European Union must be able to guarantee that people seeking healthcare abroad can use centres of excellence for health and hospital care, and that these are not only concentrated in the richer countries which have invested heavily in their healthcare systems. To this end, the European Union must support the development of systems of evaluation, certification and approval for new technologies and therapies; the effectiveness of hospital systems or any type of healthcare institution must be based on approval or certification procedures.

4.8 This quality campaign should enable the European Union to establish an EU-wide network of institutions that are host to both the scientists and highly qualified professionals who are so crucial to the existence of the centres of reference; and it is not unreasonable to hope that such centres will soon appear in certain countries of the enlarged European Union of 25, especially if the Union develops a mechanism for monitoring, analysing and exchanging information on national policies, while respecting the fundamental principles of our treaties, including subsidiarity and national remits.

4.9 By the same token, it is important not to forget the harmonisation of public health indicators. Harmonisation is useful in improving information about the health objectives of the European Union - the key indices of mortality, avoidable mortality, morbidity and avoidable morbidity - which are not necessarily equally accepted in all the EU Member States.

4.10 Differences show that results can be improved by raising healthcare to the level of the best-performing country. At the moment the five-year survival rate for lung cancer is not the same in France and Poland. Treatment of blood disorders such as leukaemia is not equally effective in the United Kingdom and France, depending on the treatment protocols used.

4.11 Information for patients, professionals and policy-makers is a key objective of the European Commission's policy.

4.12 With respect to patient information, health education refines European citizens' understanding of health, e.g. with respect to expectations and behaviour. Good health can now be seen as an absolute asset and right and in any event is a state which must be protected by the competent authorities. Meeting these expectations entails an increase in the resources allocated to pursuing health objectives involving treatment, and frequently also an increase in prevention and in attention given to environmental factors; otherwise social protection systems will be disrupted.

4.13 Health safety has become a right and a new power acquired by European Union citizens (3).

4.14 Technology, privacy, shared medical records, freedom of information and data protection are all matters that must be discussed, as transparently as possible, so that all stakeholders can be sensitised. The discussion must be ongoing, because the pace of development is rapid and decisions are difficult and/or must be taken promptly. Each of these factors is a major issue for the three sets of players in the healthcare triangle.

4.15 Reconciling national objectives with European obligations: the comparative analysis of healthcare systems raises difficult strategic issues which it must be possible to use to promote European cooperation in the healthcare sphere and to monitor the impact of the European Union on healthcare systems. For example, it is necessary to take a closer look at horizontal issues that may have serious implications, such as: good practice and efficacy in the health sector, ageing and healthcare, health in the new EU Member States, and evaluation of the impact of different health factors.

4.16 It is also urgently necessary to look at ways of ensuring legal certainty, thereby upholding patients' right to enjoy high-quality medical treatment in any EU Member State; appropriate proposals must be made by the EU in this area (to clarify the application of case law, simplify rules for coordinating social security systems, and facilitate intra-European cooperation).

4.17 The most unexpected but valuable news announced by the Commission in its communication is the use of the EU Cohesion Fund and the Structural Funds to promote investment in the sphere of health and develop health infrastructure and medical skills, which have become priority targets for support from Community financial instruments.

4.18 The European Economic and Social Committee strongly endorses this decision: a new field of action is opening up for the development and success of the European Union, especially in the context of the Lisbon Strategy.

4.19 Finally, the European Economic and Social Committee in principle supports the Commission's approach towards the health professions. The development of health systems depends on professional skills and knowledge moving forward. Healthcare requires a trained, highly-qualified workforce and continuing, life-long training.

4.20 It is the task of the European Economic and Social Committee to promote awareness of these critical healthcare issues affecting the European Union, its cohesion and its ability to become a knowledge-based economy.

4.21 The problems must be analysed and pre-empted in order to encourage professional mobility, but without destabilising national systems. The European Economic and Social Committee trusts in this connection that the directive due to be adopted on qualifications and skills, is a crucial and valuable document and one that is necessary for the completion of the internal market.

4.22 The arrangements provided for are practical and well-conceived. In addition, the European Economic and Social Committee believes that it will also be very useful to harmonise codes of conduct for all healthcare professionals and that it will be well received.

4.23 All these measures have been taken in anticipation of the shortages of healthcare professionals expected over the coming years. Investment in the healthcare professions is rewarding, profitable and expedient if the intention is to provide EU citizens with high-quality care.

4.23.1 Improving health and healthcare with the help of information and communication technologies.

4.24 The European Economic and Social Committee believes that it is from this area that the strongest arguments will come for reforming healthcare systems and improving quality in the European Union. Several components are already on the table. — With electronic, shared medical records every citizen can be given a right to social protection, a right to health and a better understanding of their health. In addition, this system provides a way to avoid abuse, the trend towards superfluous spending, drug incompatibilities and ‘medical nomadism’, as well as facilitating all patient information, reception and registration procedures. — E-medicine promises to be extremely effective for remote consultation of specialists and all healthcare stakeholders, and provision of information to which patients are justly entitled. — Health-insurance cards can be used to check immediately a patient's entitlement or situation with regard to social insurance cover. — Plus all the current and future applications that can be used to improve management of systems, develop health and public health strategies, create effective databases, evaluate the productivity of providers and obtain detailed information on consumption patterns.

4.25 Information networks are now in place, fulfilling the demands of patient organisations. However, care must be taken to ensure the protection of professional secrecy when the patient-doctor relationship is at stake.

5. Proposals of the European Economic and Social Committee

5.1 In its opinion of 16 July 2003, the European Economic and Social Committee recognised the key importance of these policies and made proposals which appear to have already been taken up by the European Commission, whose arguments are underpinned by a guiding principle.

5.2 Cooperation between the Member States must pinpoint joint objectives that lead to national plans, and the choice of appropriate indicators will make it possible to carefully monitor the development of healthcare policies pursued in each of the European Union countries.

5.3 The Committee notes that one tool will be indispensable: an observatory or agency should be set up to collect comments, analyses and exchanges of opinion on national health policy - in strict compliance with existing treaties, and the principles of subsidiarity and national remits – with special regard to the process of improving quality of care, the efforts of public authorities and managers to enhance the efficacy of all healthcare providers, public or private, and the creation of centres of excellence and their networking across the European Union, in both rich and poor regions.

5.4 A vigorous and sustained employment policy must be pursued to pre-empt anticipated manpower shortages, without waiting until there is a demand.

5.5 A health information policy must be promoted by drawing on the results of healthcare programmes, identifying the information needs of stakeholders in the system – patients, professionals and public authorities – and also taking account of sources such as the World Health Organisation and the Organisation for Economic Cooperation and Development.

5.6 The European Economic and Social Committee can only welcome the Commission's intention to use the open method of coordination (see EESC opinion of July 2003), detailing its modus operandi and specifications in advance. This would cover key issues such as: — exchange of good practice (accreditation), quality standards, equivalence of qualifications, mutual recognition of practices whose cost-reducing impact should be specified, given the wide disparity between national systems; — relevant indicators of structures and practices; — improving the availability of health products, taking account of innovation needs, the fight against public health epidemics such as AIDS, tuberculosis or malaria in the poorest countries, and efforts to reduce waste; — coordination of national systems to avoid any dumping effect due to skills being lost to other countries; — the necessary completion of the single market in medicines.

6. Conclusion

6.1 The European Economic and Social Committee is very aware that the last three Commission communications are the fruit of discussion between the five Directorates-General concerned.

6.2 This demonstrates that the European Commission has understood the implications of health policies in the context of completing the internal market and enlargement.

6.3 This is one of the first instances of five Directorates-General of the European Commission pooling their political will, skills and resources in order to achieve an objective, in this case that of giving the different countries of Europe the means to coordinate their health and social protection policies for the benefit of all EU citizens.

6.4 The European Economic and Social Committee therefore would like a lightweight but permanent task force to be set up to monitor these policies and enable the Committee to contribute its insights, expertise and experience on this matter that is so sensitive and important for all EU citizens.

Brussels, 27 October 2004. The President of the European Economic and Social Committee Anne-Marie SIGMUND

(1) Own-initiative opinion on healthcare. Rapporteur: Mr Bedossa, OJ C 234 of 30.9.2003

(2) See EESC opinion on the introduction of a European health-insurance card. Rapporteur: Mr Dantin, OJ C 220 of 16.9.2003

(3) Own-initiative opinion in the course of being prepared on health safety: a collective obligation and a new right. Rapporteur: Mr Bedossa (SOC/171)