Communication from the Commission - Follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union
Date: 2004-04-20
Institutions: European Commission
Subjects: cross-border cooperation, exchange of information, free movement of persons, health care, health care system, health policy, organisation of health care

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 20.04.2004 
COM(2004) 301 final 

COMMUNICATION FROM THE COMMISSION 

Follow-up to the high level reflection process on patient mobility and healthcare 
developments in the European Union 

EN 

   EN 

 
 
 
  
EXECUTIVE SUMMARY 

Patients  wish  to  benefit  from  high  quality  healthcare  as  close  to  home  and  as  quickly  as 
possible.  Sometimes,  however,  this  can  be  best  achieved  through  healthcare  provided  in 
another Member State. The European Union provides freedoms for citizens to seek healthcare 
in  other  Member  States,  as  confirmed  by  the  European  Court  of  Justice.  Regarding 
reimbursement  of  health  care  costs  when  patients  have  sought  medical  treatment  in  another 
Member  State,  the  Court  of  Justice  has  clarified  the  conditions  under  which  they  may  be 
reimbursed1.  Accessing  healthcare  depends  on  having  the  right  information  regarding  the 
quality,  availability  and  appropriateness  of  different  services,  and  to  have  clarity  over  the 
procedures to be followed. And when patients do seek healthcare in other Member States, it is 
essential to ensure that the well-being and safety of the patient is properly protected. 

Patient  mobility  also  has  consequences  for  health  services  and  medical  care  both  in  the 
country  where  the  patient  is  insured  and  the  country  where  care  is  provided.  Beyond  the 
consequences  of  patient  mobility,  health  systems  across  Europe  also  already  face  common 
challenges  as  they  adapt  to  constant  developments  in  medical  science,  the  ageing  of  the 
European  population,  and  rising  public  expectations.  Although  these  health  systems  are 
primarily  the  responsibility  of  the  Member  States,  cooperation  at  European  level  has  great 
potential  to  bring  benefits  both  to  individual  patients  and  to  health  systems  overall.  A 
European strategy is therefore needed to ensure that citizens can exercise their rights to seek 
care in other Member States if they wish, and that European cooperation can help systems to 
work together to better meet the challenges they face.  

For citizens, the first step must be to provide them with a clearer overview of the existing EU 
legal framework regarding access to healthcare and the reimbursement of the costs incurred in 
another Member State. Access to care for individuals of course is part of the responsibility of 
Member States for their health care and health insurance systems. Rights under Community 
law  principally  concern  reimbursement  for  healthcare  provided  in  another  Member  State. 
Based  on  the  above-mentioned,  well-established  and  constant  jurisprudence  of  the  Court  of 
Justice,  the  Proposal  for  a  Directive  on  Services  in  the  Internal  Market  clarifies  the 
authorisation  regime  for  reimbursement  of  medical  costs  incurred  in  another  Member  State. 
This Proposal, together with the proposal for modernising and simplifying Regulation (EEC) 
N°  1408/71  on  the  application  of  social  security  schemes  to  employed  persons  and  their 
families  moving  within  the  Community  provides  greater  legal  certainty  as  regards  the 
conditions for the reimbursement of healthcare costs incurred in another Member State than 
the  Member  State  of  insurance  of  the  patient.  In  the  light  of  the  above  mentioned  Court 
judgements, 

–  Any non-hospital care to which you are entitled in your own Member State you may also 
seek in any other Member State without prior authorisation, and be reimbursed up to the 
level of reimbursement provided by your own system. 

–  Any hospital care to which you are entitled in your own Member State you may also seek 
in any other Member State provided you first have the authorisation of your own system. 
This  authorisation  must  be  given  if  your  system  cannot  provide  your  care  within  a 

1 

See  in  particular  the  Kohll  judgement,  Case  C-155/96  of  28.04.98,  ECR  1998  p.  I-1931;  Smits  et 
Peerbooms judgement, Case C-157/99 of 12.07.01, ECR 2001 p. I-05473 ; Vanbraekel judgement, Case 
C-368/98  of  12.07.01,  ECR  2001  p.  I-05363,  Inizan  judgement,  Case  C-56/01  of  23.10.03,  not  yet 
published; Leichtle judgement, Case 8/02 of 18.3.04, not yet published. 

2 

 
 
  
 
                                                 
medically acceptable time limit considering your condition. Again, you will be reimbursed 
up to at least the level of reimbursement provided by your own system. 

–  If  you  wish  to  seek  treatment  abroad,  your  health  authorities  can  provide  you  with 
information  on  how  you  can  seek  authorisation  for  care  in  another  Member  State,  the 
reimbursement levels that will apply and how you can appeal against decisions if you wish 
to. 

Furthermore,  according  to  Regulation  1408/71,  if  you  are  staying  temporarily  in  another 
Member State than your own - for travel, study, posting, or seeking employment - and if you 
happen to need healthcare, it will be delivered on the same basis as to people insured in that 
country. If you have to pay for this care, then you will be reimbursed in your home country, 
on the basis of the tariffs and fees in force in the Member State where the care was delivered. 
After June 1st, 2004, you can show this entitlement using the European health insurance card, 
which will replace the current paper forms, in particular form E111. 

The Communication also sets out a range of ways in which European collaboration can bring 
concrete  benefits  to  the  effectiveness  and  efficiency  of  health  services  across  Europe.  This 
includes  European  collaboration  to  make  better  use  of  resources,  covering  issues  such  as 
developing a better understanding of the rights and duties of patients, sharing spare capacity 
between  systems  and  cross-border  care,  mobility  of  health  professionals,  identifying  and 
networking  European  centres  of  reference,  and  coordinating  assessment  of  new  health 
technologies.  It  also  covers  improving  information  and  knowledge  about  health  systems  to 
provide  a  better  basis  for  identifying  best  practice  and  ensuring  universal  access  to  high-
quality  services,  and  using  the  High  Level  Group  on  Health  Services  and  Medical  Care  to 
help those responsible for health systems to work together at European level.  

The new Member States face greater health problems than the rest of the Union but have less 
economic means to address them. Their health systems are therefore under particular pressure 
as they strive not just to improve the quality of life of their citizens, but by doing so also to 
contribute  to  the  overall  economic  growth  and  sustainable  development  of  those  countries. 
Collaboration at European level can bring particular benefits to those systems, combined with 
setting a high priority for investment in health and health infrastructure in the new Member 
States. 

The  proposals  set  out  in  this  communication  are  the  Commission’s  response  to  the 
recommendations  of  the  high  level  process  of  reflection  on  patient  mobility  and  healthcare 
developments, which was established following the conclusions of the Health Council of June 
2002. This forms part of a wider strategy. A separate communication on extending the ‘open 
method  of  coordination’  to  healthcare  and  long-term  care  sets  out  proposals  for  European 
coordination to support national strategies to reform and develop health and long-term care. A 
further communication sets out an “e-Health action plan” within the framework of a European 
e-Health Area for using information and communication technologies to help improve access, 
quality and effectiveness for health services across the Union. 

Achieving these ambitions will be a long-term and complex project, and may require further 
proposals in the future. It is nevertheless an essential endeavour. Over time, this strategy will 
repay  dividends  in  better  health  and  quality  of  life.  It  will  contribute  to  better  use  of  the 
resources invested in health systems across Europe. It will promote greater economic growth 
and more sustainable development for the Union as a whole. And, most tangibly for citizens, 
it will bring concrete benefits of European integration closer to people in their daily lives. 

3 

 
 
  
 
1. 

INTRODUCTION 

Community law provides citizens with rights to seek healthcare in other Member States and 
be  reimbursed.  The  European  Court  of  Justice  has  clarified  the  conditions  under  which 
patients  may  be  reimbursed  for  healthcare  provided  in  another  Member  State  than  the 
Member  State  of  affiliation  of  the  patient2.  Community  law  also  provides  citizens  to  have 
entitlements  to  health  care  that  they  have  acquired  in  one  Member  State  to  be  recognised 
when they move to another. However, in practice it is often not straightforward for citizens to 
exercise these rights. Moreover, when they do, this has consequences for health services and 
medical  care  both  of  the  country  where  they  are  insured  and  the  country  where  care  is 
provided.  Beyond  the  consequences  of  patient  mobility,  health  systems  across  Europe  also 
already face common challenges as they adapt to constant developments in medical science, 
the ageing of the European population, and rising public expectations. Although these health 
services and medical care are primarily the responsibility of the Member States, cooperation 
at European level has great potential to bring benefits both to individual patients and to health 
systems overall. 

A  consensus  has  therefore  developed  that  a  framework  at  European  level  to  facilitate 
cooperation  and  to  shape  developments  is  needed,  but  is  lacking.  This  was  reflected  in  the 
conclusions on patient mobility and healthcare developments in the European Union adopted 
at  the  Health  Council  of  June  2002,  which  recognised  that  there  would  be  value  in  the 
Commission  pursuing  in  close  cooperation  with  the  Council  and  all  the  Member  States  – 
particularly health ministers and other key stakeholders – a high level process of reflection. 
The Commission therefore brought together health ministers from across the Union together 
with representatives of patients, professionals, providers and purchasers of healthcare and the 
European  Parliament  in  a  high  level  reflection  process  which  agreed  a  wide-ranging  report 
including nineteen specific recommendations3.  

As  the  report  emphasised,  the  organisation  of  health  systems  is  the  responsibility  of  the 
Member  States.  The  report  of  the  reflection  process  goes  into  more  detail  on  what  national 
responsibility  for  health  systems includes,  covering  issues  such  as  how  the  health  system  is 
financed;  internal  allocation  of  resources,  setting  of  overall  priorities  for  health  expenditure 
and the right to determine the scope of public funded care; prioritisation of individual’s access 
to  the  system  (if  being  paid  for  by  the  national  scheme)  with  regard  to  clinical  need, 
management strategies within set budgets; and issues of quality, effectiveness and efficiency 
of  health  care  such  as  clinical  guidelines.  However,  whilst  respecting  the  responsibilities  of 
Member States in this area, there is nevertheless great potential for cooperation at European 
level to bring benefits to patients, to health professionals, and to those responsible for health 
systems overall.  

The  Commission  therefore  is  responding  to  these  challenges  through  an  overall  strategy  set 
out in two complementary communications. This communication responds to the report of the 
reflection  process  on  patient  mobility  and  healthcare  developments  in  the  European  Union 

2 

3 

See  in  particular  the  Kohll  judgement,  Case  C-155/96  of  28.04.98,  ECR  1998  p.  I-1931;  Smits  et 
Peerbooms judgement, Case C-157/99 of 12.07.01, ECR 2001 p. I-05473 ; Vanbraekel judgement, Case 
C-368/98  of  12.07.01,  ECR  2001  p.  I-05363,  Inizan  judgement,  Case  C-56/01  of  23.10.03,  not  yet 
published; Leichtle judgement, Case 8/02 of 18.3.04, not yet published. 
For more information and the text of the report, see 
http://europa.eu.int/comm/health/ph_overview/co_operation/mobility/patient_mobility_en.htm.  

4 

 
 
  
 
                                                 
and the recommendations it made. A separate communication4 proposes extending the ‘open 
method of coordination’ to health care and long-term care, to support the efforts of Member 
States  in  developing  high-quality,  accessible  and  sustainable  health  and  long-term  care 
services. A further communication sets out an “e-Health action plan” within the framework of 
a  European  e-Health  Area  for  using  information  and  communication  technologies  to  help 
improve access, quality and effectiveness for health services across the Union. In addition, in 
the light of the Court of Justice jurisprudence mentioned above, the Proposal for a Directive 
on  Services  in  the  Internal  Market5  together  with  the  proposals  for  modernising  and 
simplifying  Regulation  (EEC)  N°  1408/716  on  the  application  of  social  security  schemes  to 
employed  persons  and  their  families  moving  within  the  Community  provides  the  legal 
framework for reimbursement of healthcare costs incurred in another Member State than the 
Member  State  of  insurance  of  the  patient.  Together,  these  initiatives  will  enable  patients  to 
exercise  their  rights  under  Community  law  to  healthcare  in  other  Member  States  and  to 
facilitate European cooperation on health systems whilst respecting the responsibilities of the 
Member  States  for  the  organisation  and  delivery  of  health  services  and  medical  care.  They 
will also supplement the implementation of sectoral initiatives such as the High Level Group 
on Innovation and Provision of Medicines7.  

The  structure  of  this  communication  broadly  follows  the  structure  of  the  patient  mobility 
report: 

–  European cooperation to enable better use of resources 

–  information requirements for patients, professionals and policy-makers 

–  the European contribution to health objectives; 

–  and  responding  to  enlargement  through  investment  in  health  and  health 

infrastructure. 

A  table  summarising  the  Commission’s  responses  to  the  recommendations  of  the  reflection 
process is also included at annex one.  

2. 

EUROPEAN COOPERATION TO ENABLE BETTER USE OF RESOURCES 

There  are  many  existing  examples  of  European  cooperation  that  brings  concrete  benefits  to 
patients, providers and those responsible for healthcare. Cross-border care can refer to patient 
mobility within border regions, for example in the Maas-Rhine Euregio between Belgium, the 
Netherlands  and  Germany.  It  can  also  refer  to healthcare  received in  another  Member  State 
without  any  implication  of  proximity,  such  as  the  arrangements  for  referral  between  Malta 
and the UK for specialist diagnosis and treatment. 

It  is  also  clear  from  existing  variations  in  techniques,  resources  and  outcomes  that  there  is 
enormous  scope  to  improve  the  results  obtained  from  existing  resources  by  bringing 

4 

5 
6 

7 

Commission  Communication  “Modernising  social  protection  for  the  development  of  high-quality, 
accessible and sustainable health care and long-term care: support for the national strategies using the 
“open method of coordination”. 
COM(2004) 2 final of 13.01.04 
For 
further 
prot/schemes/index_en.htm. 
Further details available at http://pharmacos.eudra.org. 

http://europa.eu.int/comm/employment_social/soc-

information, 

see 

5 

 
 
  
 
                                                 
healthcare  across  the  Union  towards  the  standard  of  the  best.  Take  the  example  of  bladder 
cancer;  although  survival  rates  are  improving  in  general,  there  are  substantial  differences  in 
survival among countries in Europe, with five-year survival rates ranging from highs of 78% 
in Austria to 47% in Poland and Estonia8 (see table).  

Many of these specific areas also relate to the overall objectives of accessibility, quality and 
financial  sustainability  set  out  in  the  communication  on  extending  the  open  method  of 
coordination to healthcare and long-term care. As cooperation develops, the open method of 
coordination could provide a mechanism for structuring cooperation between Member States 
in particular areas, with specific objectives and regular reviews of progress toward them. 

5 year age standardized relative survival rate, Bladder cancer patients diagnosed during the 
period 1990-1994 

90

80

70

%

60

50

40

30

POLAND

ESTONIA

SLOVENIA

SLOVAKIA

CZECH REP.

SCOTLAND

DENMARK

ENGLAND

FRANCE

WALES

NORWAY

SWEDEN

FINLAND

ITALY

NETHERLAND

GERMANY
SPAIN

MALTA

AUSTRIA

ICELAND

2.1. 

Rights and duties of patients 

It is especially important when citizens need healthcare for them to be sure about what they 
can expect of health systems and providers of care, and what is expected of them. Statements 
or charters making these rights and duties clear already exist in many Member States. A step 
towards  establishing  clarity  at  European  level  was  taken  in  the  European  Charter  of 
Fundamental Rights, which states that “Everyone has the right of access to preventive health 
care  and  the  right  to  benefit  from  medical  treatment  under  the  conditions  established  by 
national laws and practices.  

The reflection process recommended exploring further the possibility of reaching a common 
understanding  on  patients’  rights,  entitlements  and  duties,  both  individual  and  social,  at 
European  level,  starting  by  bringing  together  existing  information  on  these  issues  and  how 
they are addressed within the Member and acceding States. The High Level Group on Health 
Services and Medical Care could take this forward, starting by identifying common elements 
across  the  EU.  These  might  include  providing  timely  and  appropriate  healthcare,  providing 
patients  with  sufficient  information  for  them  to  make  informed  choices  about  the  different 
treatment options, respecting confidentiality of health data, respecting human dignity in health 
research, and compensation for harm from negligence in healthcare, and should also take into 
consideration  the  rights  and  duties  of  health  professionals.  There  may  be  some  areas  of 

8 

EUROCARE 3 - survival of cancer patients in Europe; see http://www.eurocare.it/.  

6 

 
 
  
 
 
                                                 
difference,  but  in  time  these  discussions  could  aim  to  provide  a  consistent  framework  for 
patients’  rights  across  Europe.  This  is  an  issue  which  could  also  be  addressed  through  the 
open method of coordination, as set out in that communication.  

For  citizens,  the  first  step  must  be  a  clearer  statement  of  their  existing  rights  to  healthcare 
under Community law. Access to care for individuals is part of the responsibility of Member 
States  for  their  health  care  and  health  insurance  systems.  Rights  under  Community  law 
principally concern reimbursement for healthcare provided in another Member State, and are 
set out in the proposed directive on services in the internal market and the Regulation 1408/71 
on coordination of statutory social security schemes9, both reflecting the case-law of the Court 
of Justice. This framework reflects the following general principles: 

–  Any non-hospital care to which you are entitled in your own Member State you may also 
seek in any other Member State without prior authorisation, and be reimbursed up to the 
level of reimbursement provided by your own system. 

–  Any hospital care to which you are entitled in your own Member State you may also seek 
in any other Member State provided you first have the authorisation of your own system. 
This  authorisation  must  be  given  if  your  system  cannot  provide  your  care  within  a 
medically acceptable time limit, considering your condition. Again, you will be reimbursed 
up to at least the level of reimbursement provided by your own system. 

–  If  you  wish  to  seek  treatment  abroad,  your  health  authorities  can  provide  you  with 
information  on  how  you  can  seek  authorisation  for  care  in  another  Member  State,  the 
reimbursement levels that will apply and how you can appeal against decisions if you wish 
to. 

Furthermore,  according  to  Regulation  1408/71,  if  you  are  staying  temporarily  in  another 
Member State than your own – for travel, study, posting, or job search -, and if you happen to 
need healthcare, it will be delivered on the same basis as to people insured in that country. If 
you have to pay for this care, then you will be reimbursed in your home country, on the basis 
of the tariffs and fees in force in the Member State where the care was delivered. After June 
1st, 2004, you can show this entitlement using the European health insurance card, which will 
replace the current paper forms, in particular form E11110. 

The reflection process also invited the Commission in consultation with the Member States to 
explore  how  legal  certainty  could  be  improved  following  the  Court  of  Justice  jurisprudence 
concerning  the  right  of  patients  to  benefit  from  medical  treatment  in  another  Member  State 
and to bring forward any appropriate proposals. 

The Commission has already taken, or will take action on several aspects to improve certainty 
over  the  impact  of  the  rights  of  citizens  under  European  law  to  seek  healthcare  in  other 
Member States and be reimbursed. These include: 

–  providing better and clearer information about those rights and what they mean in 

practice, as described above; 

9 

10 

Health  care  provided  during  a  temporary  stay  has  been  addressed  in  a  recent  amendment  providing 
alignment of rights  
For  more  information  on  the  deployment  of  the  EHIC,  see  MEMO/04/75,  accessible  through  the 
RAPID database at http://europa.eu.int/rapid/start/cgi/guesten.ksh. 

7 

 
 
  
 
                                                 
–  providing  better 

legal  certainty  as  regards 

the  authorisation  regime  for 
reimbursement of health care costs incurred in another Member State, in the light 
of the jurisprudence of the Court through the Commission proposal for a Directive 
on services in the internal market (COM(2004)2);  

–  improving  the  decision-making  process  through  extending  the  application  of 
health  impact  assessment  to  assess  the  impact  on  health  services,  as  described 
under the section on better understanding the European contribution to healthcare 
objectives;  

–  simplifying  the  existing  rules  on  the  coordination  of  social  security  systems 

through the modernisation and simplification of Regulation 1408/71; 

–  facilitating  mobility  of  citizens  through  simplification  of  procedures  and  the 

deployment of the European health insurance card as from 1 June 2004;  

–  improving information about patient mobility and healthcare developments, as set 

out in the section on information; 

–  and  facilitating  cooperation at European level by establishing High  Level Group 
on  Health  Services  and  Medical  Care,  as  described  under  the  section  on  the 
European contribution to health objectives. 

The Commission also invites Member States to act to raise awareness of these initiatives and 
to improve legal certainty concerning the right of patients within their system to benefit from 
medical treatment in another Member State. It is up to each Member State to determine the 
rules  governing  rights  or  duties  of  healthcare  cover  under  their  social  security  system.  It  is 
also up to each Member State to determine the conditions on which benefits provided by their 
sickness  insurance  scheme  are  granted.  EC  rules  on  free  movement  require  only  that  these 
conditions be neither discriminatory nor an obstacle to freedom of movement of persons, of 
services and  of  establishment.  Member States could therefore  review their  systems  to  see  if 
they  wish  to  clarify  the  benefits  they  provide  and  the  conditions  for  access  to  them.  For 
example, Member States could improve legal certainty within their own systems by making 
any conditions for access to healthcare explicit and transparent. The Commission is ready to 
support such efforts, for example by exchanging information through the High Level Group 
on Health Services and Medical Care and possibly by developing guidance at European level.  

The initiatives described above will go a long way to address the concerns over legal certainty 
raised by the reflection process. The responsibility of Member States for health services and 
medical care is also clearly recognised in the EC Treaty, as well as in how they are interpreted 
and implemented by the European institutions. Other options remain available for the future, 
including further legal clarification at European level, but these should be considered in the 
light  of  the  measures  already  described  in  this  Communication  and  further  developments  in 
this sector 

The  Commission  will  develop  materials  to  provide  more  information  based  on  these 
principles and detailed provisions for citizens across the Union, together with relevant contact 
points for different systems in the Member States. Existing citizens’ information offices such 
as the European Consumer Centres and Euro Info Centres could also help to raise awareness 
of  these  rights,  and  we  will  work  to  ensure  that  citizens  can  receive  concrete  advice  on 
resolving any difficulties they encounter when exercising their rights in practice. 

8 

 
 
  
 
2.2. 

Sharing spare capacity and trans-national care 

As the report of the reflection process sets out, cooperation between healthcare systems can 
bring benefits for patients and for better functioning of systems overall, for example in border 
regions  or  where  there  are  capacity  constraints.  Many  such  projects  already  exist,  and  have 
developed a wide range of solutions to the practical difficulties of cross-border cooperation. 
However, because these projects have largely grown up out of local initiatives, there is limited 
pooling of knowledge at European level on the lessons learnt.  

The  reflection  process  recommended  evaluating  existing  cross-border  health  projects,  in 
particular Euregio projects, and developing networking between projects in order to share best 
practice. The Commission plans to support a project under the public health programme11 to 
evaluate  Euregio  health  projects  and  to  assess  the  most  successful  regions  in  terms  of 
cooperation  on  health  care.  This  study  plans  to  collect  information  through  interviews  with 
the best existing cross-border health projects and will disseminate results through workshops, 
a  conference  and  a  website.  The  Commission  will  also  look  at  how  to  support  networking 
between these projects and will make any appropriate proposals.  

The reflection process also invited the Commission to explore whether it is possible to draw 
up  a  clear  and  transparent  framework  for  healthcare  purchasing  which  competent  bodies  in 
Member  States  could  use  when  entering  into  agreements  with  each  other,  and  to  make  any 
appropriate  proposals.  The  first  step  should  be  to  gather  information  on  any  existing 
arrangements for healthcare purchasing, including any formal agreements between purchasers 
and  providers  in  different  EU  countries  that  provide  mechanisms  to  enable  patients  to  have 
healthcare in other Member States. We will invite Member States to provide information on 
such arrangements through the High Level Group on Health Services and Medical Care, and 
will consider with the Member States how best to proceed once the information is available, 
perhaps  including  a  common  objective  on  this  topic  as  part  of  the  open  method  of 
coordination on healthcare and long-term care.  

2.3. 

Health professionals 

Mobility  in  the  field  of  health  is  not  only  about  patients;  health  professionals  also  move 
between  countries.  This  is  facilitated  by  European  rules  on  the  recognition  of  professional 
qualifications.  These  rules  are  currently  being  simplified  on  the  basis  of  the  proposal  for  a 
Directive on the recognition of professional qualifications (COM(2002) 119), which aims to 
ensure  clear,  simple  and  transparent  recognition  procedures  through  consolidation  of  the 
current legislation in this field, in particular regarding automatic recognition for some health 
professions.  It  also  introduces  some  new  elements  for  other  health  professions,  such  as  a 
possibility  for  automatic  recognition  on  the  basis  of  professional  platforms.  The  reflection 
process  encouraged  ongoing  work  by  the  Commission,  Council  and  Parliament  to  ensure 
clear, simple and transparent recognition procedures incorporating a high degree of automatic 
recognition  as  with  the  current  sectoral  rules  in  order  to  facilitate  and  develop  mobility  of 
health professionals. The Commission will continue to take forward this work with the other 
institutions involved in order to adopt the Directive as soon as possible.  

One  particular  issue  being  addressed  in  these  discussions  is  the  notification  of  professional 
malpractice procedures, in order to identify the most appropriate method to ensure adequate 

11 

Decision No 1786/2002/EC of the European Parliament and of the Council of 23 September 2002 
adopting a programme of Community action in the field of public health (2003-2008), OJ L 271 of 
9.10.2002. 

9 

 
 
  
 
                                                 
confidential  exchange  of  information  relevant  to  the  free  movement  of  health  and  other 
professionals. Preparatory work has already been undertaken through a project called “Sysex” 
in Belgium, which provides citizens with information on rules and procedures for professional 
recognition, allows on-line applications for recognition, and enables confidential information 
exchange  between  the  responsible  authorities.  The  Commission  and  the  Member  States  are 
considering whether it is feasible to extend this project across the EU.  

More generally, information on the number of health professionals, their specialisations, and 
their  distribution  is  important  for  planning  and  providing  health  services.  The  reflection 
process invited Member and acceding States and the Commission to develop and reinforce the 
system of gathering accurate data about the mobility of health professionals and encouraged 
Member and acceding States to collect and share comparable workforce data regarding health 
professionals, in collaboration with the Commission and relevant international organisations. 
This data should be gathered through the existing committees on recognition of professional 
qualifications,  but  in  practice  the  statistics  provided  by  the  Member  States  through  these 
committees  for  the  health  professions  are  far  from  complete.  The  Commission  calls  on 
national health authorities to provide these committees with up-to-date and complete statistics 
on the movement of health professionals for the purposes of both cross-frontier provision and 
permanent establishment in another Member State. 

Gathering  this  information  is  especially  important  given  the  existing  shortages  of  health 
professionals  in  some  Member  States.  These  shortages  will  be  compounded  in  the  coming 
years  by  the  ageing  of  the  health  workforce.  Between  1995  and  2000,  the  number  of 
physicians under the age of 45 across Europe dropped by 20%, whilst the number aged over 
45 went up by over 50%. For nurses as well, average ages are rising; in five Member States 
nearly half of nurses are aged over 45. If these trends continue, shortages will become critical 
across the whole Union in the coming decades. Facilitating mobility can go some way toward 
ensuring that health professionals go where they are most needed. But if the overall numbers 
and specialisations of health professionals are not adequate, this still represents a serious risk 
for health systems across the Union, with the impact being felt hardest in the poorest Member 
States.  In  this  context,  it  will  be  difficult  for  any  one  country  to  invest  in  training  health 
professionals  without  knowing  that  other  countries  will  do  likewise.  A  concerted  European 
strategy covering issues such as monitoring, training, recruitment and working conditions of 
health professionals could ensure that Member States would see a return on their investment 
in  health  professionals  and  that  the  Union  as  a  whole  will  be  able  to  meet  its  objectives  of 
providing high-quality healthcare. The Commission invites the Member States to consider this 
issue, in collaboration with the health professions.  

2.4. 

European centres of reference 

As set out by the reflection process, European centres of reference could provide healthcare 
services to patients who have conditions requiring a particular concentration of resources or 
expertise  in  order  to  provide  high  quality  and  cost-effective  care,  in  particular  for  rare 
diseases.  Centres  of  reference  could  also  be  focal  points  for  medical  training  and  research, 
information  dissemination  and  evaluation.  Any  system  of  European  centres  of  reference 
should  be  flexible,  objective  and  transparent,  with  clear  criteria,  scientific  and  health 
professional involvement, and should take into account the need for services and expertise to 
be appropriately distributed across the enlarged European Union.  

The  reflection  process  invited  the  Commission,  in  collaboration  with  the  Member  and 
acceding  States,  to  carry  out  a  mapping  exercise  relating  to  centres  of  reference  taking  into 
account the principles set out above, and to explore how to foster networking and cooperation 

10 

 
 
  
 
on  these  issues,  including  the  organisation,  designation  and  development  of  centres.  The 
Commission will take this recommendation forward through a call for tender under the public 
health  programme.  On  the  basis  of  the  results  of  this  project  we  will  consider  any  specific 
proposals  on  these  issues  at  European  level,  including  any  new  cooperation  structures  and 
methods  for  identifying  centres  of  reference  across  Europe.  Collaboration  in  this  area  has 
great  potential  to  bring  benefits  to  patients  through  easier  access  to  highly  specialised  care, 
and to health systems by making the most efficient possible use of resources, for example by 
pooling resources to tackle rare conditions. 

2.5. 

Health technology assessment 

Developments in health technology have been a key element in the massive improvement of 
human health in modern times. Health technology in this sense includes health-related devices 
and products as well as techniques. Progress in health technology has not only allowed us to 
develop  more  effective  therapies  than  before,  but  also  to  widen  the  scope  of  health 
intervention in order to treat previously untreatable conditions.  

Partly  because  of  this,  developments  in  health  technology  are  the  largest  factor  behind  the 
increases in expenditure of European health systems in recent decades. We all wish to benefit 
from the most effective healthcare available. However, the most expensive or the most recent 
treatment is not necessarily the most effective. New developments in health technology need 
to be properly evaluated and compared with other options in order to provide a solid evidence 
base for healthcare decisions. Health technology assessment can be used to assess the safety, 
effectiveness  and  wider  implications  of  different  health  technologies.  As  yet,  this  kind  of 
evaluation is not sufficiently undertaken, and existing work across the Union is fragmented. 
An  example  is  the  pharmaceutical  sector  where  though  assessments  of  clinical  and  cost 
effectiveness  of  medicines  are  becoming  a  regular  feature  of  of  most  national  healthcare 
pricing and reimbursement schemes, they operate in a variety of different ways. Cooperation 
at  European  level  can  bring  added  value  by  sharing  information,  avoiding  duplication  and 
coordinating  activities  to  achieve  maximum  results.  Some  work  has  already  begun  in  the 
pharmaceutical  sector  through  the  Transparency  Committee  established  under  Directive 
89/105/EEC. 

The reflection process invited the Commission to consider how a sustainable network and co-
ordination function for health technology assessment could be organised and funded, and to 
make  any  appropriate  proposals.  We  can  build  on  collaboration  and  projects  already 
supported under the public health programmes to harmonise methodology for assessments and 
to explore the role of health technology assessment in the future systems of health care in the 
Member States. The Commission plans to establish a coordinating mechanism to link together 
the different projects, organisations and agencies which already exist and to pool results and 
information in a usable and effective way, and will bring forward separate specific proposals, 
including for a study. The cost-effectiveness of health technologies may also be the subject of 
specific objectives within the open method of coordination proposed for health and long-term 
care.  These  initiatives  will  help  to  ensure  that  patients  throughout  Europe  benefit  from  care 
reflecting the latest advances in medical technology, and also that health systems can ensure 
that they are using their limited resources in the most effective and efficient way. 

11 

 
 
  
 
3. 

INFORMATION 

3.1. 

Health systems information strategy 

Information  about  health  systems  is  vital.  It  underpins  the  ability  of  citizens  to  use  health 
systems;  of  professionals  to  diagnose,  treat  or  refer;  and  of  health  authorities  to  plan  and 
manage systems as a whole. At a European level, information is the basis of identifying best 
practice  and  comparing  standards.  Many  aspects  of 
this 
communication  depend  on  appropriate  information.  Yet  one  of  the  effects  of  the  primarily 
national focus on health systems is that information is lacking at the European level. 

the  strategy  outlined 

in 

A  strategy  is  required  for  developing  information  on  health  systems  for  the  future.  The 
reflection process invited the Commission to develop a framework for health information at 
EU  level  building  on  the  results  of  the  public  health  programme,  including  identifying 
different information needs from the perspective of policy-makers, patients and professionals; 
how that information can be provided; the responsibilities of the different actors concerned; 
and taking account of relevant work by the WHO and the OECD. The report also identified a 
range  of  areas  where  more  information  is  required,  from  information  related  to  the  detailed 
provision of healthcare to setting up a framework for systematic data collection on the volume 
and nature of patient movement, including data on tourism-related flows and long-term stay.  

Work is already underway to improve information on patient mobility and mobility of health 
professionals  at  European  level.  This  is  being  taken  forward  in  the  health  systems  working 
party that has been set up under the first strand of the public health programme. This expert 
group will meet twice annually and will advise the Commission on how to meet information 
needs  in  the  field  of  health  systems,  including  dissemination  of  results.  This  can  build  on 
work begun by the health monitoring programme through twelve projects in the field of health 
systems  information  covering  hospital  data,  primary  care,  pharmaceuticals,  efforts  in 
prevention and health promotion, health care professionals and an umbrella project providing 
descriptive information on health care provision actors and activities. The work of the health 
systems working party is closely coordinated with the Community statistical programme12 and 
in particular with the core group on health care statistics, and also with the ongoing work in 
OECD and WHO. The framework programmes for research and technological development13 
can  also  contribute;  for  example,  one  forthcoming  project  will  address  performance 
assessment of health care institutions to assess and compare different quality strategies.  

The  information  strand  of  the  public  health  programme  is  also  developing  the  concept  of  a 
European  Public  Health  Portal.  The  portal  will  serve  as  a  single  point  of  access  to 
thematically arranged health information produced with Community funding. Specifically, it 
will  give  access  to  Community  health  indicators  on  six  themes  (mortality  and  morbidity, 
injuries and accidents, lifestyles, health and environment, mental health and health systems) 
and  analysis  on  the  basis  of  the  indicators  and  policy  recommendations.  In  addition,  the 
Commission,  the  European  Medicines  Evaluation  Agency  and  the  Member  States  are 
implementing an informatics strategy for the pharmaceutical sector which contains a proposal 
for  establishing  a  EuroPharm  database  containing  a  harmonised  set  of  information  on  all 
licensed  medicines  in  the  EU.  This  will  also  form  part  of  a  broader  strategy  to  improve  the 

12 
13 

See Council Regulation (EC) No 322/97 of 17 February 1997 on Community Statistics. 
Decision No 1513/2002/EC of the European Parliament and of the Council of 27 June 2002 concerning 
the Sixth Framework Programme of the European Community for research, technological development 
and demonstration activities, contributing to the creation of the European Research Area and to 
innovation (2002 to 2006), OJ L 232/1 of 29.08.2002. 

12 

 
 
  
 
                                                 
quality of existing consumer information on medicines. These initiatives will provide a solid 
basis for developing a coherent European information strategy for health systems as a whole. 

3.2.  Motivation for and scope of cross-border care  

The reflection process specifically identified the need for more information on the motivation 
for  and  the  scope  of  cross  border  care,  inviting  the  Commission  to  carry  out  a  study  to 
establish  the  motivation  for  patients  to  move  across  borders,  the  specialities  affected,  the 
nature of bilateral agreements, the information requirements of patients and clinicians and the 
patient experience,  with particular  regard to enlargement. The  Commission plans to  address 
this through a specific study under the public health programme, as well as through a research 
project  “Europe  for  Patients”  examining  the  benefits  and  challenges  of  enhanced  patient 
mobility in Europe. 

3.3. 

Data protection 

The  reflection  process  also  raised  specific  concerns  about  data  protection  and  sharing  of 
confidential data between Member States and at EU level, inviting the Commission to address 
this issue. These issues are covered by Directive 95/46/EC14 on the protection of individuals 
with regard to the processing of personal data and on the free movement of such data. 

The  objective  of  this  Directive  is  to  harmonise  data  protection  legislation  in  the  Member 
States  in  order  to  facilitate  the  free  movement  of  personal  data  within  the  Union  while 
protecting the fundamental rights and freedoms of natural persons. The Directive contains a 
general prohibition on processing sensitive data, including data concerning health, but with a 
limited  number  of  exceptions.  In  particular,  the  general  prohibition  on  processing  sensitive 
data may be lifted if the subject of the data gives their explicit consent, provided that the laws 
of the Member State concerned allow individuals to give such consent. Health data may also 
be  processed  in  situations  where  this  is  required  for  the  purposes  of  preventive  medicine, 
medical  diagnosis,  the  provision  of  care  or  treatment  or  the  management  of  health  care 
services,  and  where  those  data  are  processed  by  a  health  professional  who  is  subject  to  the 
obligation  of  professional  secrecy  or  by  another  person  also  subject  to  an  equivalent 
obligation of secrecy.  

This  provides  a  framework  for  handling  personal  data  and  health  data  in  cross-border  care. 
However, awareness of these provisions may not be sufficient in the health sector. If they are 
not  applied,  this  may  mean  that  the  privacy  of  citizens  is  not  properly  respected  –  or 
conversely,  that  relevant  information  for  their care  does  not  follow  patients  when  they  seek 
care  elsewhere  within  the  Union.  The  Commission  will  work  with  the  Member  States  and 
with  the  national  data  protection  authorities  to  raise  awareness  of  these  provisions  as  they 
apply to healthcare and to address any outstanding issues if needed.  

3.4. 

E-health 

Use of information technology offers great potential for patients, professionals and for health 
systems overall. Health-related information is already one of the most searched-for topic on 
the internet, as citizens look to be better informed about their health and decisions affecting it. 
Some health-related services are also available using information technology, both to patients 
and  to  professionals.  The  Commission  is  taking  forward  actions  to  promote  e-health,  in 

14 

OJ L 281 of 23/11/1995. 

13 

 
 
  
 
                                                 
particular through the public health programme and as part of the e-Health action plan. Issues 
of  interoperability  and  compatibility  among  health-related  information  systems  are  of 
particular  importance  in  this  regard.  The  reflection  process  invited  the  Commission  to 
consider establishing European principles concerning the competence and the responsibilities 
of all those involved in e-health service provision.  

Directive 2000/31/EC15 on electronic commerce contributes to the legal certainty and clarity 
needed for information society service providers to be able to offer their services throughout 
the  Union.  Of  course,  activities  which  cannot  be  provided  on-line,  such  as  medical  advice 
requiring  a  physical  examination  of  the  patient  are  not  information  society  services  and 
remain subject to the rules of the Member State where the service is provided. In any event, 
requirements for the protection of public health established in Community law apply whether 
the health services concerned are provided on-line or off-line; likewise, Member States may 
also take action to restrict the provision of services from another Member State where this is 
necessary  to  protect  public  health,  subject  to  the  conditions  established  in  the  directive  on 
electronic commerce. 

Nevertheless, beyond this general framework there is scope to improve clarity over legal and 
ethical issues related to e-health. The Commission has already presented, a Communication in 
2002  defining  quality  criteria  for  health  related  websites16.  This  focused  primarily  on  the 
reliability of health related websites, and presented a set of commonly agreed quality criteria 
which  website  operators  should  apply  in  addition  to  relevant  Community  law.  The 
Commission plans to consider these issues further as part of the eEurope 2005 action plan and 
the specific actions on eHealth17.  

4. 

EUROPEAN CONTRIBUTION TO HEALTH OBJECTIVES 

Ensuring  a  high  level  of  health  and  well-being  for  citizens  throughout  Europe  is  a  value 
shared by the whole Union. Some European action is directly focused on health, such as the 
public  health  programme  or  legislation  to  ensure  the  safety  of  blood  and  blood  products. 
Other actions have different primary aims but also integrate health protection requirements in 
their  definition  and  implementation,  as  required  by  the  Treaty  establishing  the  European 
Community (Article 152, paragraph 1).  

Member States themselves also of course act to achieve this shared commitment to health and 
well-being for their citizens, in which their health systems are crucial. The health systems of 
the Member States also share fundamental principles: universal access on the basis of need, 
high-quality health provision, and financial sustainability on the basis of solidarity. European 
rules  and  actions  have  an  increasing  role  to  play  in  meeting  health  objectives,  and  these 
principles are proposed as common objectives for open coordination on health care and long-
term  care.  At  the  heart  of  the  reflection  process  was  the  need  to  develop  a  better 
understanding  of  the  contribution  of  the  Union  to  ensuring  a  high  level  of  health  and  well-
being  for  citizens  throughout  Europe,  and  for  the  political  authorities  responsible  for  health 
and health systems to have a stronger role in shaping that European contribution.  

15 
16 

17 

OJ L 178 of 17/07/2000. 
Communication “eEurope 2002: Quality Criteria for Health related Websites”, (COM (2002) 667 final, 
adopted on 29.11.2002. 
Commission  Communication  “e-Health  -  making  healthcare  better  for  European  citizens:  An  action 
plan for a European e-Health Area”. 

14 

 
 
  
 
                                                 
4.1. 

Improving  integration  of  health  objectives  into  all  European  policies  and 
activities 

The European contribution to high levels of health protection for European citizens needs to 
be better analysed and understood. The reflection process invited Member and acceding States 
to  provide  their  views  on  how  the  different  access  routes  for  healthcare  in  other  Member 
States  operate  in  their  country  and  their  impact,  in  particular  with  regard  to  access  routes 
arising  from  European  rules.  The  Commission  will  work  with  Member  States  to  gather  this 
information through the High Level Group on Health Services and Medical Care and taking 
account of data assembled under the information strategy described above.  

More  generally,  the  reflection  process  invited  the  Commission  to  prepare  an  analysis  of 
Community  activities  to  see  how  these  can  better  contribute  to  access  and  quality  in 
healthcare,  taking  account  of  relevant  activities  in  other  international  organisations,  and  to 
review  evidence  related  to  the  issues  raised  by  the  interaction  of  Community  rules  and 
national  health  policy  objectives.  The  reflection  process  also  invited  the  Commission  to 
provide  a  review  of  evidence  relevant  to  the  issues  raised  by  the  interaction  of  Community 
rules and national health policy objectives. 

At European level, the Commission is already working to ensure that assessing the impact of 
European initiatives on health objectives is integrated into overall impact assessments of new 
initiatives. The Treaty provisions on health require a high level of human health protection to 
be ensured in the definition and implementation of all Community policies and activities. As 
well as the impact on the overall health of citizens, this assessment should also take account 
of  the  impact  on  health  systems  and  their  objectives.  The  public  health  programme  is 
supporting  work  to  refine  methods  of  health  impact  assessment,  including  specific  case 
studies  on  Community  policies,  legislation  and  actions;  mapping  the  use  of  health  impact 
assessment in the Member States; and evaluating the way health has been taken up by other 
impact  assessment  methodologies  and  in  particular  ‘integrated’  assessment  tools.  The 
Commission  will  build  on  this  work  to  ensure  that  the  impact  of  future  proposals  on  health 
and healthcare is taken into account in their overall integrated assessment. 

4.2. 

Establishing  a  mechanism  to  support  cooperation  on  health  services  and 
medical care 

It  is  clear  that  there  is  a  need  to  facilitate  European  cooperation  on  health  services  and 
medical  care  whilst  respecting  the  responsibilities  of  the  Member  States  in  this  area.  This 
must  closely  involve  the  Member  States  in  order  to  ensure  that  national,  regional  and  local 
levels are fully involved in and aware of the European context to their work. The reflection 
process  invited  the  Commission  to  consider  the  development  of  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, and to bring forward any appropriate proposals. 

In  accordance  with  Article  152,  paragraph  2,  the  Community  shall  encourage  cooperation 
between  the  Member  States  in  the  areas  referred  to  in  that  article  and,  if  necessary,  lend 
support  to  their  action.  Member  States  shall,  in  liaison  with  the  Commission,  coordinate 
among  themselves  their  policies  and  activities  in  particular  with  regard  to  improving  public 
health,  preventing  human  illness  and  disease,  and  obviating  sources  of  danger  to  human 
health.  Such  action  shall  cover  the  fight  against  the  major  health  scourges,  by  promoting 
research  into  their  causes,  their  transmission  and  their  prevention,  as  well  as  health 
information and education. The  Commission may, in close contact with the Member States, 
take any useful initiative to promote such coordination. 

15 

 
 
  
 
Further  to  these  provisions,  and  building  on  the  success  of  the  reflection  process,  the 
Commission has  decided to establish a  “High Level Group on Health Services and Medical 
Care”, based on the following principles: 

–  role:  high  level  group  to  support  European  cooperation  between  the  Member  States  on 
health services and medical care, in order to help patients to have the high-quality health 
care they seek and to help health systems to improve their effectiveness and efficiency. 

–  activities:  to  promote  cooperation  between  the  Member  States  and  take  forward  the 
recommendations  of  the  reflection  process  through  activities  such  as  developing  a  better 
understanding of the rights and duties of patients, sharing spare capacity between systems 
and  cooperating  on  cross  border  care,  identifying  and  networking  European  centres  of 
reference, and coordinating assessment of new health technologies.  

–  membership: senior representatives of Member States, normally at the level of Directors-

General, and the Commission, calling on external experts as necessary; 

–  legal  basis:  established  by  a  Commission  decision  and  implementing  the  provisions  of 
paragraph  2  of  Article  152  on  public  health  of  the  Treaty  establishing  the  European 
Community,  to  support  the  cooperation  and  coordination  between  the  Member  States 
provided for in that paragraph in the area of health services and medical care. 

–  links  with  other  bodies:  The  group  will  work  closely  with  other  relevant  bodies  at 
European  and  international  level,  in  particular  the  Social  Protection  Committee  and  the 
Economic Policy Committee.  

–  involvement  of  other  stakeholders:  Civil  society  stakeholders  from  the  health  sector 
should  also  be  involved  on  a  regular  basis,  in  particular  through  the  European  Union 
Health  Forum.  Representatives  of  regional  and  local  authorities  with  responsibility  for 
healthcare should also be able to contribute, as in most Member  States the responsibility 
for providing health services is at regional or local level. 

Health  services  and  medical  care  are  primarily  the  responsibility  of  the  Member  States  and 
should remain so. However, it is clear from the conclusions of the reflection process that there 
is great potential for cooperation at European level to help patients to have high-quality health 
care  and  to  help  health  systems  to  improve  their  effectiveness  and  efficiency.  Respecting 
national  responsibility  for  health  systems  does  not  mean  doing  nothing  at  European  level. 
Rather,  this  committee  can  ensure  that  there  are  structures  in  place  to  facilitate  cooperation 
where useful and ensure that where Europe does have an impact on health or health systems, 
it  does  so  in  a  positive  way  and  that  those  responsible  for  achieving  health  objectives  can 
shape those developments. 

5. 

RESPONDING  TO  ENLARGEMENT  THROUGH  INVESTMENT  IN  HEALTH  AND  HEALTH 
INFRASTRUCTURE 

Every  Member  State  of  the  Union  faces  challenges  in  meeting  its  health  objectives.  These 
challenges  are  particularly  acute  for  the  new  Member  States.  Not  just  the  quality  of  life  of 
their citizens, but the overall economic growth and sustainable development of these countries 
depends on investing in health and health systems. This investment must be a priority both for 
the  countries  concerned  and  for  the  Union.  However,  enlargement  will  also  help  the  new 
Member States to better cope with their problems since it sustains the economic development 

16 

 
 
  
 
of the relevant countries. Moreover, already the market opening has shown positive influences 
on the development of the state of health due to the access to better or higher quality products 
which is likely to continue and further improve after accession. 

The state of health in the new Member States varies, but life expectancy in all is significantly 
lower  than  in  the  current  Union;  men’s  health  is  particularly  poor.  Prevalence  of  major 
western  diseases  is  higher  than  in  the  current  Union,  such  as  cardiovascular  disease  and 
cancer  –  especially  lung  cancer.  Risk  factors  are  also  greater  than  in  the  current  Union,  for 
example  with  higher  rates  of  smoking  and  alcohol  consumption,  and  low  levels  of  physical 
exercise.  Health  systems  across  the  acceding  States  have  been  reformed  with  a  focus  on 
decentralisation,  reform  of  insurance  and  funding  systems,  and  more  efficient  use  of 
resources. But the overall level of resources invested in healthcare is still much lower than in 
the current Union – around 4.5% on average of Gross Domestic Product (GDP), compared to 
8.5% GDP for the current Union.  

Poor  health  status  compounded  by  under-investment  in  health  and  health  systems  will  be  a 
major  brake  on  development,  if  it  is  not  addressed.  Health  is  a  productive  factor  in  a 
competitive economy. The cost every time a worker is absent is not just the direct cost of their 
sickness  payments,  but  also  the  cost  of  their  replacement  by  other  workers  and  lower 
productivity  for  their  employer  as  a  whole.  For  workplace  accidents  alone,  this  cost  is 
estimated to represent 1-3% of GNP a year. At a macro level, health is crucial to raising the 
activity  level  of  the  population.  Chronic  illness  affects  about  15%  of  the  working  age 
population in the European Union. This represents a burden not just for sufferers but for those 
who care for them; about 15 million people in the current EU need the assistance of a third 
person to fulfil the basic functions of normal life. 

On  the  positive  side,  increased  longevity  and  better  overall  health  increases  the  potential 
return to people from investing in their own education and training. It also gives people the 
confidence  and  capabilities  to  remain  active  longer.  Early  investment  in  health  reduces 
subsequent  costs  for  the  economy  as  a  whole.  The  future  economic  growth  and  sustainable 
development of the entire Union therefore depends on investment in health - investment that 
will  be  doubly  important  for  the  new  Member  States  to  reduce  the  gap  with  the  rest  of  the 
Union. 

The reflection process invited the Commission, Member and acceding States 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 one 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, including: 

–  in the “Health” operational programme  in Portugal, € 475m is being invested in 
order  to  promote  health  and  prevent  illness,  improve  access  to  healthcare,  and 
develop partnership in the health sector; 

–  in  the  “Ceuta”  programme  in  Spain  (overall  budget  €  105.5m),  the  “urban  and 
local development” strand will support technological renovation and improvement 
of health centres and hospitals.  

–  in  the  regional  programmes  for  Epirus  and  continental  Greece  (overall  budget  € 
1,553m),  infrastructure  and  urban  improvement  programmes  include  support  for 
health-related activities.  

17 

 
 
  
 
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  additional  European  investment  in  health  infrastructure  will 
also  be  addressed  as  part  of  developing  the  new  financial  perspectives  for  the  Union  from 
2006.  

6. 

CONCLUSION 

The  health  ministers  and  other  stakeholders  involved  in  the  high  level  reflection  process  on 
patient mobility and healthcare developments in the European Union identified a wide range 
of  issues  where  progress  is  needed.  The  report  of  the  reflection  process  also  represents  a 
milestone  by  recognising  the  potential  value  of  European  cooperation  in  helping  Member 
States to achieve their health objectives.  

Developing  the  European  response  to  these  issues  through  the  initiatives  set  out  in  this 
communication, the communication on extending the open method of coordination to health 
and long-term care and the communication on the European e-Health Area (and its associated 
action  plan  on  e-Health)  will  be  a  long-term  project  requiring  significant  resources.  Further 
proposals  beyond  those  set  out  at  this  stage  may  also  be  needed.  However,  over  time  this 
effort will repay dividends in better health and quality of life; in better use of the resources 
invested in health systems across Europe; in  greater  economic growth  and more sustainable 
development  for  the  enlarged  Union  as  a  whole;  and  in  bringing  concrete  benefits  of 
European integration closer to citizens in their daily lives. 

18 

 
 
  
 
ANNEX 1  

SUMMARY OF THE RECOMMENDATIONS OF THE REFLECTION PROCESS AND THE 
COMMISSION’S RESPONSES 

RECOMMENDATIONS 

COMMISSION RESPONSES 

Rights and duties of patients 

To  explore  further 
the  possibility  of 
reaching  a  common  understanding  on 
patients’  rights,  entitlements  and  duties, 
both  individual  and  social,  at  European 
level, starting by bringing together existing 
information  on  these  issues  and  how  they 
are  addressed  within  the  Member  and 
acceding States. 

To  be  taken  forward  through  the  High 
Level  Group  on  Health  Services  and 
Medical Care, starting by bringing together 
existing  information  as  recommended  by 
the reflection process. 

Sharing spare capacity and trans-national care 

To  evaluate  existing  cross-border  health 
projects, in particular Euregio projects, and 
to develop networking between projects in 
order to share best practice. 

The  Commission  is  supporting  work  to 
evaluate  Euregio  projects  under  the  public 
health  programme,  and  will  look  how  to 
support networking between these projects. 

invite 

to  explore 
the  Commission 
To 
whether  it  is  possible  to  draw  up  a  clear 
and  transparent  framework  for  healthcare 
purchasing  which  competent  bodies  in 
Member  States  could  use  when  entering 
into  agreements  with  each  other,  and  to 
make any appropriate proposals.  

The Commission will invite Member States 
to  provide  information  on  any  existing 
arrangements  for  healthcare  purchasing 
through  the  High  Level  Group  on  Health 
Services  and  Medical  Care,  and  will 
consider  with  the  Member  States  how  to 
proceed once that information is available.  

Health professionals 

To invite Member and acceding States and 
the  Commission  to  develop  and  reinforce 
the system of gathering accurate data about 
the mobility  of health professionals and  to 
encourage  Member  and  acceding  States  to 
collect  and  share  comparable  workforce 
in 
data  regarding  health  professionals, 
collaboration  with  the  Commission  and 
relevant international organisations.  

The  Commission  calls  on  the  Member 
States  to  provide  up-to-date  and  complete 
the  movement  of  health 
statistics  on 
structures 
the 
through 
professionals 
governing 
recognition  of  professional 
qualifications.  The  Commission  will  also 
continue  work  to  ensure  clear,  simple  and 
transparent recognition procedures together 
with the Council and Parliament.  

19 

 
 
  
 
 
 
 
simple  and 

the 
To  encourage  ongoing  work  by 
Commission,  Council  and  Parliament  to 
ensure  clear, 
transparent 
recognition  procedures 
incorporating  a 
high  degree  of  automatic  recognition  as 
with  the  current  sectorial  rules  in  order  to 
facilitate  and  develop  mobility  of  health 
professionals. 

The  Commission  will  also  continue 
preparatory  work  with  the  Member  States 
to  ensure  adequate  confidential  exchange 
free 
relevant 
of 
other 
health 
movement 
professionals.  

information 
of 

to 
and 

the 

The Commission invites Member States to 
consider issues related to current and future 
shortages  of  health  professionals  in  the 
Union.  

European centres of reference 

To invite the Commission, in collaboration 
with  the  Member  and  acceding  States,  to 
carry  out  a  mapping  exercise  relating  to 
centres of reference taking into account the 
principles  set  out  above,  and  to  explore 
how  to  foster  networking  and  cooperation 
on these issues, including the organisation, 
designation and development of centres. 

The  Commission  will  take  this  forward 
through  work  under  the  public  health 
programme,  and  will  consider  any  further 
proposals on that basis.  

Health technology assessment 

To invite the Commission to consider how 
a  sustainable  network  and  co-ordination 
function  for  health  technology  assessment 
could  be  organised  and  funded,  and  to 
make any appropriate proposals.  

The  Commission  proposes  addressing  this 
through  specific  proposals,  including  a 
specific study with a view to developing a 
collaboration  mechanism  as  part  of 
cooperation  on  health  services,  and  will 
bring 
if 
appropriate.  

separate  proposals 

forward 

Health systems information strategy 

The  Commission  will  take  this  forward 
through  the  information  strand  of  the 
public  health  programme,  in  particular 
through 
the  working  party  on  health 
systems  and  with  dissemination  through 
the planned public health portal. This work 
will  be  carried  out  in  close  collaboration 
with other relevant bodies at European and 
international level. 

To  invite  the  Commission  to  develop  a 
framework  for  health  information  at  EU 
level  building  on  the  results  of  the  public 
health  programme,  including  identifying 
the 
information  needs 
different 
perspective  of  policy-makers,  patients  and 
professionals; how that information can be 
provided  and  the  responsibilities  of  the 
taking 
different  actors  concerned,  and 
account of relevant work by the WHO and 
the OECD.  

from 

To  invite  the  Commission  to  facilitate 
information  sharing  at  European  level  on 
possible  available  healthcare,  existing 

20 

 
 
  
 
 
 
of 

care, 

records, 

entitlements 

nomenclature 

supply 
and 
procedures, costs, prices, adverse incidents, 
patient 
of 
conditions,  treatments  and  products,  and 
continuity  and  quality  of  care  across  the 
Union, as part of the overall framework for 
information  discussed  in  the  section  on 
information  below.  Action  could  include 
to  networking  and  developing 
support 
databases. 

To  invite  the  Commission  to  explore  how 
to  set  up  a  framework  for  systematic  data 
collection across the enlarged Union on the 
volume  and  nature  of  patient  movement, 
the  systems 
both  within  and  outside 
established  by  Regulation  1408/71  and 
including data on tourism-related flows and 
long-term stay. 

Motivation for and scope of cross-border care 

to  establish 

to  move  across  borders, 

To  invite  the  Commission  to  carry  out  a 
the  motivation  for 
study 
patients 
the 
specialities affected, the nature of bilateral 
agreements,  the  information  requirements 
of  patients  and  clinicians  and  the  patient 
experience,  with  particular 
to 
enlargement. 

regard 

The  Commission  proposes  to  address  this 
through  a  specific  study  under  the  public 
health  programme,  and  it  will  also  be 
addressed  by  the  research  project  “Europe 
for Patients”. 

Data protection 

To invite the Commission to address issues 
concerning  data  protection  and  sharing  of 
confidential  data  between  Member  States 
and at EU level. 

This  communication  provides  a  short 
description  of  how  data  protection  rules 
take account of the specific nature of health 
data.  The  Commission  will  work  with  the 
Member  States  through  the  High  Level 
Group  on  Health  Services  and  Medical 
Care to raise awareness of these provisions 
and to address any outstanding issues.  

E-health 

To  invite  the  Commission  to  consider 
principles 
European 
establishing 
concerning 
the 
responsibilities  of  all  those  involved  in  e-
health service provision. 

the  competence  and 

The Commission will consider these issues 
in  more  detail  as  part  of  its  overall  action 
plan  for  e-health,  as  set  out 
the 
Communication  on  “e-Health  –  making 
healthcare  better  for  European  citizens:  an 
action plan for a European e-Health area”. 

in 

21 

 
 
  
 
 
 
Improving integration of health objectives into all European policies and activities 

To  invite  Member  and  acceding  States  to 
provide  their  views  on  how  the  different 
in  other 
access  routes  for  healthcare 
Member States operate in their country and 
their impact, and to invite the Commission 
and  the  Member  States  to  consider  any 
appropriate options for responding. 

The  Commission  will  work  with 
the 
Member  States  to  gather  this  information 
through  the  High  Level  Group  on  Health 
Services and Medical Care, taking account 
of 
the 
assembled  under 
information strategy described above.  

the  data 

To  invite  the  Commission  to  prepare  an 
analysis  of  Community  activities  to  see 
how  these  can  better  contribute  to  access 
and quality in healthcare, taking account of 
relevant  activities  in  other  international 
organisations.  

To  invite  the  Commission  to  provide  a 
review  of  evidence  relevant  to  the  issues 
raised  by  the  interaction  of  Community 
rules and national health policy objectives. 

regarding 

The  Commission  will  build  on  existing 
projects 
impact 
assessment  to  ensure  that  the  impact  of 
future Commission proposals on health and 
healthcare  is  taken  into  account  in  their 
overall impact assessment. 

health 

Establishing a mechanism to support cooperation on health services and medical 
care 

To  invite  the  Commission  to  consider  the 
development of 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, 
and  to  bring  forward  any  appropriate 
proposals. 

The  Commission  has  established  a  High 
Level  Group  on  Health  Services  and 
Medical Care.  

Developing a shared European vision for health systems 

certainty 
the 

To  invite  the  Commission  in  consultation 
with  the  Member  States  to  explore  how 
improved 
could 
legal 
Justice 
following 
Court 
jurisprudence  concerning 
the  right  of 
patients  to  benefit  from  medical  treatment 
in  another  Member  State  and  to  bring 
forward any appropriate proposals 

be 

of 

The Commission is proposing to extend the 
open method of coordination to health care 
separate 
care 
long-term 
and 
communication. 

in 

a 

The Commission has or will take action on 
several  aspects  to  improve  legal  certainty 
in  this  area,  including  providing  better 
information about rights to seek healthcare 
to  be 
in  other  Member  States  and 
reimbursed;  clarifying  the  application  of 
existing jurisprudence through the directive 
internal  market; 
the 
on 

services 

in 

22 

 
 
  
 
 
 
improving assessment of the health impact 
of  European  proposals;  simplifying  the 
rules  on  coordination  of  social  security 
systems and improving their usability with 
insurance  card; 
the  European  health 
improving 
patient 
knowledge 
mobility and healthcare developments; and 
facilitating  cooperation  at  European  level 
by  establishing  a  High  Level  Group  on 
Health Services and Medical Care.  

about 

The  Commission  also 
invites  Member 
States  to  act  to  improve  legal  certainty 
within  their  systems,  and  is  ready  to 
support  such  initiatives,  for  example  by 
exchanging  information  or  possibly  by 
developing guidance at European level.  

Responding to enlargement through investment in health and health infrastructure 

to  consider  how 

To  invite  the  Commission,  Member  and 
acceding  States 
to 
facilitate  the  inclusion  of  investment  in 
health,  health  infrastructure  development 
and skills development as priority areas for 
funding 
existing  Community 
financial instruments 

under 

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 
should  also  be 
addressed  as  part  of  developing  the  new 
financial  perspectives  for  the  Union  from 
2006. 

infrastructure 

23