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)
Date: 2004-10-27
Institutions: European Economic and Social Committee
Subjects: ESC opinion, EU Member State, cross-border cooperation, enlargement of the Union, exchange of information, free movement of persons, health care, health care system, health policy, organisation of health care

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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 communi-
cation.

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

in the light of European commitments that are gradually
growing and giving new rights to Europe's citizens.

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 thera-
peutic 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 diag-
nostic 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.

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

limiting patient mobility makes it easier

This new situation now guides the debate between those
1.4
who maintain that
this freedom of choice will produce a
harmful destabilisation of current healthcare systems, on the
grounds that
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

In its own-initiative opinion of 16 July 2003 (1), the
2.1
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.’

In that opinion,

forward arguments

the European Economic and Social
2.2
and proposed work
Committee put
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.

1.3
These factors are already making it necessary to evaluate
national policies, which must take all these needs into account,

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

234 of 30.9.2003

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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
these
services, which has to do with citizens' safety and equal treat-
ment.

the special nature of

is taken of

2.4
The Commission also published the two communica-
tions 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 citi-
zens to use healthcare facilities in other countries of the Union,
as well as clarifying the conditions for reimbursing the costs of
healthcare.

Since 1 June 2004, Europe's citizens can prove their
2.5
entitlement with a future European health-insurance card (1),
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 incapaci-
tating 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, informa-
tion for patients, professionals and policy-makers, access to
high-quality care,
reconciling national health policies with
European obligations, etc.

(1) See EESC opinion on the introduction of a European health-insurance

card. Rapporteur: Mr Dantin, OJ C 220 of 16.9.2003

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 reimburse-
ment 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.

It

3.3
strategy to:

therefore seems necessary to develop a European

3.3.1
resources:

promote European cooperation to allow better use of

— 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 frame-
work for the purchase of healthcare, which the relevant autho-
rities 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 struc-
tures governing recognition of professional qualifications.
The Commission will also continue work with the Council
and Parliament to ensure simple and transparent recogni-
tion 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.

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— The Commission will ask Member States to consider issues
related to current and future shortages of health profes-
sionals in the Union.

— European centres of reference: the European Commission
the public health
will
programme in order to draw up a list of reference centres,
before making proposals.

tender under

issue a call

for

— improving the integration of health objectives into all Euro-
pean 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;

— Health technology assessment: the Commission will intro-
duce a coordinating mechanism for the evaluation of health
technologies, and will present separate specific proposals to
this end.

— the Commission will also build on ongoing projects
the
regarding health impact assessment
effects of
future Commission proposals on health and
healthcare are taken into account in their overall assess-
ment;

to ensure that

3.3.3 Meeting the information requirements of patients,
professionals and policy-makers:

— health systems information strategy: the European Commis-
sion 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 Organi-
sation 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 Euro-
pean principles on the competence and responsibilities of
all those involved in providing e-health services, the Euro-
pean 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
objectives:

Strengthening the Union's role in achieving healthcare

— establishing a mechanism to support cooperation on health
services and medical care: in response to a request to estab-
lish a permanent mechanism at EU level to support Euro-
pean 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
in health and health infrastructure.

Responding to enlargement by expanding investment

In fact,

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 infra-
structure development and skills development as priority areas
for funding under existing Community financial instruments, in
particular in Objective 1 areas.
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 iden-
tifying 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 struc-
tures for the financial
instruments concerned to ensure that
health is given the necessary weight in the development of
in health
overall plans. The need for European investment
infrastructure should also be addressed in connection with
developing the new financial perspectives for the Union from
2006.

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4. Specific comments

The free movement of patients in the Member States
4.1
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 preven-
tive policies that are currently attracting the attention of all
stakeholders - health professionals, the media and political deci-
sion-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.

systems of

development of
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.

evaluation,

This quality campaign should enable the European
4.8
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 moni-
toring, analysing and exchanging information on national poli-
cies, while respecting the fundamental principles of our treaties,
including subsidiarity and national remits.

By the same token,

it is important not to forget the
4.9
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.

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

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

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.

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

stakeholders

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.

4.7
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

4.13
acquired by European Union citizens (1).

Health safety has become a right and a new power

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

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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.

4.21
The problems must be analysed and pre-empted in
order to encourage professional mobility, but without destabi-
lising 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.

4.15
Reconciling national objectives with European obliga-
tions: 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).

The most unexpected but valuable news announced by
4.17
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.

The European Economic

and Social Committee
4.18
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. Health-
care requires a trained, highly-qualified workforce and conti-
nuing, life-long training.

In addition,

The arrangements provided for are practical and well-
4.22
the European Economic and Social
conceived.
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
in the healthcare professions is
coming years.
rewarding, profitable and expedient
the intention is to
if
provide EU citizens with high-quality care.

Investment

4.23.1
information and communication technologies.

Improving health and healthcare with the help of

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 super-
and ‘medical
fluous
nomadism’, as well as facilitating all patient information,
reception and registration procedures.

incompatibilities

spending, drug

— 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 insur-
ance cover.

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

— 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 informa-
tion on consumption patterns.

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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
Committee

the European Economic

and Social

In its opinion of 16 July 2003, the European Economic
5.1
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 indispen-
sable: 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

Brussels, 27 October 2004.

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 prac-
tices 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.

This demonstrates that the European Commission has
6.2
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 contri-
bute its insights, expertise and experience on this matter that is
so sensitive and important for all EU citizens.

The President

of the European Economic and Social Committee

Anne-Marie SIGMUND