Study on cross-border health services : enhancing information provision to patients : executive summary.
Date: 2018-08-27
Institutions: Directorate-General for Health and Food Safety
Subjects: cross-border cooperation, financing, health care, health care system, health policy, organisation of health care, patient's rights, provision of services, regional policy, social security

Study on cross-border health 
services: enhancing 
information provision to 
patients 

Executive Summary (EN)  

Written by the consortium of Ecorys, KU Leuven and GfK Belgium.  

June – 2018 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Directorate-General for Health and Food Safety 
Directorate B — Health systems, medical products and innovation 
Unit B.2 — Cross-border healthcare; Tobacco control 

Contact: Anne-Marie YAZBECK 

 Corina VASILESCU 

E-mail: SANTE-Cross-border-Healthcare@ec.europa.eu  

Anne-Marie.YAZBECK@ec.europa.eu 
Corina.VASILESCU@ec.europa.eu  

European Commission 
B-1049 Brussels 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Study on cross-border health 
services: enhancing 
information provision to 
patients 

Executive Summary (EN)  

Consumer, Health, Agriculture and Food Executive Agency 
Health Programme 

2018 

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Study on cross-border health services: enhancing information provision to patients  

EXECUTIVE SUMMARY 

EU  legislation  established  a  broad  set  of  patients’  rights  with  regard  to  accessing  health  services 
abroad. However, currently much of the potential of these provisions in increasing patient mobility 
remains unused. Due to low patient awareness, shortcomings in information provision and existing 
regulatory and procedural barriers, patients are limited in their possibilities to benefit from seeking 
cross-border  healthcare.  As  recommended  in  previous  studies,  elimination  of  existing  barriers  in 
some Member States (MSs), as well as more uniform practice of information provision in line with 
the  requirements  under  Directive  2011/24/EU,  is  required.  These  improvements  are  key  in 
providing  citizens  with  more  equal  opportunities  to  exercise  their  rights  to  planned  treatment 
abroad.  

Against  this  background,  the  overall  objective  of  this  study  was  to  propose  recommendations  for 
improving the current level of information provision to patients in cross-border healthcare. To that 
end, the study aimed to: 

 

Identify  the  legal  information  requirements,  as  well  as  the  needs  of  patients,  for  the 
National Contact Points (NCPs) (of the  MS  of treatment and of the  MS of affiliation  where 
the  patient  is  normally  insured)  and  for  healthcare  providers  who  provide  cross-border 
services; and to 

  Study and assess the status quo  of  current information provision by NCPs, as well as the 
degree  of  evolution  since  previous  studies  undertook  similar  performance  measurement 
exercises.  

To  achieve  these  two  aims,  we  used  a  combination  of  research  methods,  including  a  literature 
review, an analysis of legal texts,  a website analysis, a pseudo-patient investigation, and surveys 
among NCPs and patients.  

This  study  went  beyond  the  existing  literature  by  not  only  mapping  the  status  quo,  but 
subsequently also developing a toolbox and training material for the NCPs to improve the quality of 
information  provision  to  patients  on  cross-border  healthcare.  More  specifically,  tools  and  training 
materials, as well as a set of Guiding Principles and indicators were developed in order to establish 
an NCP service that is in line with the requirements of Directive 2011/24/EU, that is more uniform, 
and that is patient-centred. This will contribute to high level information provision to patients. 

The  draft  results  of  the  research  activities  were  shared  and  discussed  with  the  NCPs  through 
bilateral  exchanges  and  during  an  NCP  workshop  on  March  8  2018  in  Brussels.  The  Guiding 
Principles were shared with to the NCPs for a final round of consultation in June 2018. 

Results of the literature review 

Central in the process of improving access to planned cross-border healthcare is the need for good 
information provision. Information provision  must be  seen as a powerful tool in safeguarding free 
provision of services  and free movement of patients at  all times.  Enhancing information provision 
needs to be considered at different levels:  

  Clear, accurate and accountable information empowers patients to exercise their rights and 

 

 

 

 

to make informed choices in cross-border healthcare; 
Informing  healthcare  providers  on  patients’  rights  to  cross-border  healthcare  ensures 
access to health services abroad for patients and safeguards non-discrimination of patients 
based on nationality; 
Informing  NCPs  and  healthcare  providers  on  the  legal  framework  for  cross-border 
healthcare  and  on  the  information  requirements  placed  under  Directive  2011/24/EU, 
enables them to provide patients with clear, accurate and accountable information; 
Informing  MSs  and  national  authorities  of  their  obligations  to  safeguard  equality  in 
accessing  health  services  abroad  may  contribute  to  lower  procedural  barriers  and  lower 
limitations  set  on  patient  in  and  outflow,  which  are  not  justified  by  overriding  reasons  of 
general interest; 
Informing  patients  on  practicing  healthy  lifestyle  habits  can  have  a  huge  impact  at  little 
expense to anyone and great benefit to many. Guiding patients, cultivating awareness and 
information-seeking behaviour across the socio-economic spectrum of society is an intrinsic 
part of leading and inspiring a healthy lifestyle.  

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Study on cross-border health services: enhancing information provision to patients  

Our study of the literature showed that limited numbers of patients make use of their right to seek 
treatment in another MS. However, many Europeans are willing to consider treatment abroad. The 
main reasons for Europeans to go abroad for medical care are to receive treatment that is not yet 
available  in  their  home  MS,  or  to  receive  better  quality  treatment.  There  are  some  socio-
demographic  factors  determining  the  willingness  of  patients  to  go  abroad  (more  specifically:  age, 
employment and education) which prima facie appear to mirror health inequality disparities within 
the  MSs.  The  limited  number  of  patients  seeking  cross-border  treatment  can  be  explained  by  a 
general lack of awareness  of  the  existence  of  the  Directive 2011/24/EU  and  more  importantly,  of 
NCPs.  

Results of an Evaluative study published in 2015 have shown that information provision to patients 
by NCPs has significantly improved over the years, e.g. NCPs provide more information and more 
information  is  provided  in  English.  Nevertheless,  it  is  shown  that  there  is  still  a  great  need  for 
improvement  on  different  aspects.  It  is  e.g.  shown  that  information  on  quality  and  safety  is  not 
always provided in a sufficient  manner.  Moreover, patient organisations have stated that patients 
often  find  it  important  to  be  able  to  compare  the  treatment  they  can  receive  abroad  with  the 
treatment offered in the home MS, enabling them  to weigh their different options, which today is 
often  not  possible.  Full  and  accurate  translations  to  English  are  also  still  missing  on  some  NCPs’ 
websites.  The  accessibility  of  these  websites  for  incoming  patients  traveling  from  other  EU/EEA 
countries can be questioned. 

Information provision still differs greatly between NCPs, as some provide detailed information and 
some (too) general information. This makes it difficult for the patient to understand the information 
provided.  Authors  therefore  point  out  the  importance  for  NCPs  to  evolve  to  a  more  common  and 
uniform  way  of  providing  information.  To  that  end,  cooperation  between  NCPs  and  with  other 
actors is of great importance. 

Core finding 1: 
There is a general lack of awareness of the existence of the Directive 2011/24/EU 
and  NCPs.  The  findings  of  the  study  show  that  almost  five  years  after  the 
implementation  of  Directive 2011/24/EU, patients’  awareness on  their  rights and 
possibilities to access health services abroad and on the existence of NCPs is still 
low. 

Website analysis: an analysis of information provision on NCP websites 

The  second  part  of  this  study  focussed  on  the  evaluation  of  the  information  provision  to  patients 
through the NCP websites. The methodology for the website analysis was based on the Evaluative 
Study  (fieldwork  carried  out  in  2014)  in  which  Specific  Analytical  Items  (SAI)  were  developed  to 
structure  the  website  analysis.  Based  on  a pilot  that  was  conducted  as  part  of  the  current  study, 
analysis of relevant legal texts, a literature review, and a review of studies on quality assessment 
of websites aimed at patients, the methodology for the website analysis was refined and updated. 

The analysis of the NCP websites was performed in July 2017. Data was collected on 36 websites 
hosted  by  33  dedicated  NCPs;  the  UK  has  separate  websites  for  England,  Scotland,  Wales, 
Northern Ireland,  and Gibraltar, Luxembourg  and Sweden have  two NCP websites due to the  fact 
that  different  organisations  are  responsible  for  information  provision  for  incoming  and  outgoing 
patients, and Slovakia has two websites hosted by the same NCP. After data collection, the results 
on the individual SAIs were used to calculate the SAI category scores per NCP website. In the end, 
the  website  analysis  looked  at  nine  SAI  categories,  with  three  focussed  on  the  website  itself  (in 
terms of technical elements, accessibility, and usability)  and six categories focussed on the actual 
content of the website.  

The three SAI categories that focussed on the website itself, and their results, are:  

  Technical elements 

This SAI category focussed on the presence of certain technical elements, such as contact 
information  and  the  last  date  of  update.  The  NCPs  scored  relatively  well  on  the  SAIs 
regarding  the  technical  elements  of  the  websites,  with  an  average  of  72%,  ranging  from 
14% to 100% of the total points earned. 

  Accessibility 

This SAI category  focused on the ease  with  which the NCP website can be  found, opened 
and used, and includes SAIs such as the `availability of options for people with decreased 
sensory functioning’ and ‘order in Google search strategy’. The analysis did not reveal any 

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Study on cross-border health services: enhancing information provision to patients  

major issues regarding the accessibility of the NCP websites. The combined average score 
of the NCPs is 60%, ranging from 17% to 92% of the total points earned. 

  Usability 

This SAI category concerned elements of the website that make the website easy to use for 
visitors.  Examples  of  included  SAIs  are:  the  presence  of  most  visited  pages,  an  internal 
search  engine  and  a  media  library.  The  average  combined  score  of  the  NCPs  was  55%, 
ranging from 30% to 90% of the total points earned. Only 5 out of 36 websites contained a 
media  library  hosted  on  the  NCP  website.  In  contrast,  31  out  of  36  websites provided  an 
internal  search  engine,  which  drastically  improves  the  ability  of  visitors  to  navigate  the 
website.  

The six SAI categories that focussed on the actual content of the website, and their results, are:  

  General information on cross-border healthcare 

This  category  focussed  on  the  content  that  is  available  on  the  websites.  Among  other 
things,  the  NCP  websites  were  scored  on  containing  general  information  concerning  the 
Regulation  (EC)  883/2004  and  Directive  2011/24/EU  and  the  distinction  between  these 
legal instruments, as well as information on patient rights. The combined average scores of 
the NCPs was 72%, ranging from 0% to 100%. Most websites included a dedicated section 
for  inbound  patients,  and  general  information  on  patients’  rights  regarding  cross-border 
care.  Yet,  a  little  less  than  half  of  the  websites  included  information  on  the  EU  Directive 
2011/24/EU  and  the  Regulation  (EC)  883/2004,  and  also  provided  some  form  of 
comparison between these two pieces of legislation. 
Information on healthcare providers 
A  combined  average  score  of  59%  was  achieved  by  the  NCPs  on  in-depth  information  on 
the topic of the health system of the NCP’s MS and details on healthcare providers. There 
was  a  wide  variation  in  scores,  which  ranged  between  0%  to  100%.  A  clear  and 
comprehensive overview of the structure of the healthcare system in the NCPs' respective 
countries was broadly lacking, and requires extra attention. 
Information on patients’ rights 
A  combined  average  score  of  25%  was  achieved  for  this  category,  which  shows  that  in-
depth  information  on  patient  rights  is  generally  lacking  on  the  NCP  websites.  The 
percentages range from 0% to 78%. Specific SAIs of concern are ‘information on patients’ 
rights in case of undue delay’ and ‘presence of information on complaint procedures in case 
of  follow-up  treatment  issues’,  with  only  2  and  4  out  of  36  NCP  websites  containing 
relevant information respectively.  From  a more positive  perspective, 21 websites included 
(detailed) information on mechanisms to  settle  disputes and 17 included information on  a 
patient’s rights in case of harm. 
Information on prior authorisation 
In  order  to  receive  reimbursement  of  healthcare  costs,  patients  should  in  certain 
circumstances request prior authorisation from their insurance provider. For this category, 
the  NCP  websites  received  a  little  less  than  half  of  the  points  available,  with  a  combined 
average score of 48%, which ranged between 0% to 100%. A total of 26 websites included 
information on how to obtain reimbursement, and 24 included specific information on what 
treatments  require  prior  authorisation.  The  websites  scored  poorly  on  the  SAI  concerning 
the  availability  of  information  on  the  time  period  required  for  prior  authorisation  requests 
to be dealt with. 
Information on quality and safety standards 
In  order  to  make  an  informed  decision,  patients  require  information  on  the  national 
strategy  and  policies  regarding  quality  and  safety  of  healthcare.  In  this  study,  the  NCPs 
scored poorly on whether information was provided on their website regarding quality and 
safety standards. The combined average score of the NCP websites was 30%,  and ranged 
between  0% to 100%.  In  this category,  scores on the different SAIs were broadly similar 
across the NCP websites. Consequently, 70% of the analysed websites did not include any 
(relevant) information on quality and safety standards. 
Information on entitlement for reimbursement of costs 
The  combined  average  score  of  the  NCP  websites  on  information  concerning  the 
reimbursement of costs was 25%, and ranged between 0% to 83%. A total of 19 out of 36 
websites included at least some  form  of information on which treatments are reimbursed. 
However, only 4 websites included specific details on which treatments are not reimbursed. 
Additionally, the SAIs on the time period required for reimbursement to be dealt with and 
information  on  specific  reimbursement  tools  were  among  the  worst  scoring  SAIs  of  the 
website analysis.  

 

 

 

 

 

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Study on cross-border health services: enhancing information provision to patients  

Core finding 2: 
The  information  provision  through  NCP  websites  was  adequate,  even  so  there 
remains a need to further improve the NCP websites. In particular, information on 
patient’s rights (for incoming patients), quality and safety standards (for incoming 
patients)  and  reimbursement  of  cross-border  healthcare  costs  (for  outgoing 
patients) require additional consideration and improvement.  

Pseudo-patient  investigation:  an  analysis  of  information  provision  by  NCPs 
though email and telephone 

A pseudo-patient investigation was conducted as a follow-up to the Evaluative Study on the Cross-
border Healthcare Directive 2011/24/EU. The main objective of this exercise was to investigate the 
differences, or discrepancies, between: 

 

 

the  information  that  was  provided  by  NCPs  in  response  to  enquiries  made  by  pseudo-
patients; and  
the  information  that  NCPs  are  expected  to  provide  based  on  the  provisions  of  the  Cross-
border Healthcare Directive.  

In  order  to  accomplish  this,  the  pseudo-patient  investigation  was  conducted  in  the  form  of  a 
traditional pseudo-patient investigation exercise. A total of 116 pseudo-patient investigations were 
conducted  in  29  countries.  The  fieldwork  was  conducted  between  21  August  2017  and  24 
November 2017. 

The exercise was based on pseudo-patient scenarios, which considered three key criteria:  

 
 
 

the type of request (incoming vs. outgoing patient); 
the type of institution (individual practitioners vs. large establishments); and  
the type of service (private vs. public).  

The  Directive  2011/24/EU  clearly  places  distinctive  information  requirements on  NPCs,  depending 
on their role as NCP of the MS of affiliation or NCP of the MS of treatment. As the set of information 
requirements  differs  depending  on  the  NCP’s  role,  information  provision  to  both  outgoing  and 
incoming  patients  should  be  evaluated  equally.  Furthermore,  previous  studies  show  that 
information provision to incoming patients is often failing, especially with regard to information on 
quality  and  safety  standards.  Hence,  the  importance  to  also  investigate  the  status  quo  of 
information provision in the NCP’s role as NCP of the MS of treatment. 

Table 1 General description of the 4 scenarios 

Description 

Enquiry 

Localisation 
Type of service 
Service provider 

Scenario 1 
Physical movement 
of the patient 
across the border 

Scenario 2 
Physical movement 
of the patient 
across the border 

Scenario 3 
Provision of services 
across a border 

Scenario 4 
Provision of services 
across a border 

A spread of two different enquiries across these two scenarios requiring prior 
authorisation or not 

Outgoing 
Purely private 
Individual 
practitioners 

Outgoing 
Public 
Large 
establishments 

Incoming 
Purely private 
individual 
practitioners 

Incoming 
Public 
large 
establishments 

Country coverage 

EU 28 Member States + Norway (taking into account regional disparities) 

As previously mentioned, a distinction in scenarios was made based on the type of health service 
the pseudo-patient wishes to receive. Two scenarios illustrate an inquiry from a patient who wishes 
to receive treatment with a healthcare provider who works within the public system (scenario 2 and 
4).  Generally,  this  will  be  a  public  healthcare  provider.  However,  this  can  also  be  a  private 
healthcare provider that is contracted  or affiliated with the public system and thus is also entitled 
to  provide  services  covered  under  the  social  security  scheme.  The  other  two  scenarios  concern 
questions  about  health  services  provided  by  healthcare  providers  offering  purely  private  services 
(scenario  1  and  3).  The  rationale  for  this  distinction  is  the  scope  of  applicability  of  Directive 
2011/24/EU  and  the  Social  Security  Regulations  respectively.  The  Social  Security  Regulations  do 
not  apply  to  healthcare  that  is  provided  by  a  healthcare  provider  who  is  solely  authorised  to 

8 

 
 
 
 
 
 
Study on cross-border health services: enhancing information provision to patients  

provide purely private health services. In case of the latter, only Directive 2011/24/EU will apply. 
Directive  2011/24/EU  applies  to  healthcare  provided  by  both  public  and  private  healthcare 
providers.  This  distinction in  scenarios  was  made  to  test if  NCPs  inform  patients  correctly on  this 
difference in application and are able to assist patients under both legal instruments.  

Two  scenarios  related  to  health  services  provided  by  individual  practitioners  (scenario  1  and  3). 
The  two  others  concerned  patients  requesting  information  on  healthcare  provided  in  larger 
establishments. This distinction was made to test if NCPs are able to answer questions relating to 
different  types  of  situations.  As  a  result,  also  the  specific  types  of  health  services  differ  between 
scenarios  (consultation,  surgery,  common  operation  with  waiting  lists,  rarer  interventions,..).  In 
addition,  a  distinction  was  made  between  health  services  involving  an  overnight  hospital  stay  or 
not, as the latter will often determine whether or not prior authorisation will be required.  

The scenarios covered all EU28 MSs and Norway. When contacting NCPs during this task, regional 
disparities across health systems in different MSs were taken into account for each scenario.  This 
included taking into account MSs with a decentralised healthcare system and following up with the 
relevant authorities in each case. 

During  the  pseudo-patient  investigation,  the  NCPs  were  first  contacted  by  email.  After  an 
incomplete  response,  or  after  two  weeks  without  a  response,  the  NCPs  were  contacted  via 
telephone,  where  possible.  Three  NCPs  only  allowed  for  contact  via  email  and  did  not  provide  a 
telephone number that could be used. 

Looking at all scenarios, the majority (83%) of pseudo-patients were able to get into contact with 
the  NCP  and  make  enquiries.  In  the  2015  Evaluative  Study,  only  two  out  of  12  NCPs  were  not 
reached in one of the three scenarios. 19 out of 29 NCP could be reached for the four scenarios. In 
17% of the scenarios, NCPs could not be reached by the pseudo-patients, or they were unable to 
get a response to questions. One NCP could never be reached or pseudo-patients were never able 
to make inquiries in any of the four scenarios during the open field period of 7 full weeks, the exact 
same result having been obtained in the mystery shopping round of 2014. 

To  analyse  the  information  provision  of  the  NCPs,  all  items  of  the  four  different  scenarios  were 
taken  into  consideration.  Each  item  was  analysed  according  to  whether  information  was  provided 
or  not.  The  correctness  of  the  information  was  not  taken  into  consideration.  55%  of  the  NCPs 
responded to at least half of the questions in the email or telephone inquiries, on average. 24% of 
the  NCPs  was  able  to  respond  to the  majority  of  questions,  on  average.  This  shows  that  there  is 
room  for  improvement  for  some  NCPs  –  and  for  NCPs  to  learn  from  each  other’s  best  practices  - 
and suggests high information provision potential of the NCPs in the future. 

Based  on  the  feedback  received  from  the  NCPs  during  the  bilateral  exchanges,  some  constraints 
were reported explaining why communication or information provision was limited. The constraints 
include  the  request  by  the  NCPs  for  personal  patient  information  or  additional  documentation  in 
order to be able to proceed with communication, which could not be provided during the pseudo-
patient investigation. 

Results of the NCP and patient survey 

To launch the NCP survey, an e-mail was sent to the NCPs of all 28 MSs and Norway, as well as to 
Iceland. In case of multiple CPs (contact points) per MS, the RCPs (Regional Contact Points) were 
given  the  opportunity  to  participate  separately.  The  survey  was  open  from  17  August  until  9 
November  2017.  We  achieved a response  rate  of 94%. A  total of  31 NCPs, representing 28  MSs, 
completed  the  survey  (n  =  31  NCPs).  In  addition,  four  RCPs  participated  separately.  Two  NCPs 
(single  NCPs  of  different  MSs)  remained  non-responsive,  however,  one  of  these  did  provide  the 
requested information during the bilateral exchange that followed the roll-out of the survey.  

The  NCP  survey  showed  that  there  are  big  organisational disparities  between NCPs  regarding  the 
number  of  NCPs,  the  institution  hosting  the  NCP,  the  NCP  funding  and  staff,  as  well  as  the 
organisational  handling  of  incoming  and  outgoing  patients.  Overall,  NCPs  indicated  experiencing 
significant  improvements  since  the  implementation  of  Directive  2011/24/EU.  However,  they  also 
indicated that there is still room for further improvement regarding comparability of invoices, NCP 
websites,  visibility  of  NCPs  and  patient  awareness,  as  well  as  regarding  cooperation  and 
information exchange between NCPs.  

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Study on cross-border health services: enhancing information provision to patients  

Core finding 3: 
There  are  big  organisational  disparities  between  NCPs  regarding  the  number  of 
NCPs  in  each  MS,  the  institution  hosting  the  NCP,  funding  and  staff,  and 
organisational  handling  of 
incoming  and  outgoing  patients.  Significant 
improvements  have  been  achieved  since  the  implementation  of  the  Directive 
2011/24/EU  and  the  establishment  of  the  NCPs,  which  did  not  predate  the 
Directive.  However,  there  is  still  room  for  further  improvement  regarding 
comparability of invoices, NCP websites, visibility of NCPs and patient awareness, 
as well as regarding cooperation and information exchange between NCPs.  

A  survey  for  patients  who  have  made  use  of  the  possibility  to  receive  healthcare  in  another  MS, 
was open from 17 August to 18 December 2017. 48 patient organisations were contacted, covering 
(national  coalition  and  specialised)  organisations  in  all  28  EU  MSs  and  Norway.  These  patient 
organisations  were  asked  to  assist  in  sending  an  e-mail  and  the  URL  of  the  online  survey  to 
patients with recent experience with cross-border healthcare.  

In  total,  the  responses  of  11  patients  were  included  in  the  data  analysis,  corresponding  to  more 
than 50 planned cross-border healthcare events (ranging from 1 to 20 events per patient; mean of 
6  events  per  patient).  As  a  result,  the  sample  size  was  too  small  to  draw  any  valid  and 
representative  quantitative  conclusions.  Nevertheless,  the  patient  survey  yielded  relevant 
qualitative information based on the comments provided by patients throughout the survey. These 
comments were used to validate quantitative findings of the study. 

The patient survey showed that patients’ awareness of their rights and possibilities to access health 
services abroad and on the existence of NCPs is still low. As with the website analysis, information 
for incoming patients – in English – regarding patients’ rights and quality and safety standards was 
mentioned  to  be  lacking.  For  outgoing  patients,  the  study  revealed  shortcomings  in  information 
provision concerning undue delay and waiting times.  

The  surveys  amongst  NCPs  and  patients  confirmed  the  notion  that  information  provision  for 
inbound patients is in general less complete than for outbound patients. Another important finding 
of the study was that a high number of  NCPs still experience  difficulties in communicating on the 
differences  between  Directive  2011/24/EU  and  the  Social  Security  Regulations,  while  this  is 
potentially important information for patients to obtain when seeking cross-border healthcare. 

Core finding 4: 
Information provision for incoming patients is in general less complete compared 
to  information  targeted  at  outgoing  patients.  This  has  been  concluded  from  the 
website  analysis,  the  online  surveys,  and  to  a  lesser  extent  from  the  pseudo-
patient investigation.  

Toolbox and Guiding Principles 

Central  in  developing  the  Guiding  Principles  and  the  toolbox,  was  the  goal  to  ensure  information 
provision  in  accordance  with  the  legal  requirements  placed  on  NCPs  and  healthcare  providers  by 
Directive 2011/24/EU as well as to ensure equal access to quality information for patients. As long 
as this goal is achieved, NCPs are free to organise themselves according to their own insights and 
wishes. All instruments were validated by the NCPs themselves, during bilateral exchange and the 
NCP workshop on 8 March 2018. In addition, the policy proposal instruments were developed based 
on  already  established  NCP  practice,  in  all  EU  Member  States  and  Norway  and  the  Guiding 
Principles were shared with to the NCPs for a final round of consultation in June 2018. 

Another important finding of the study was that a high number of NCPs still experience difficulties 
in  communicating  the  inter-linkages  between  Directive  2011/24/EU  and  the  Social  Security 
Regulations,  while  this  is  very  important  information  for  patients  when  seeking  cross-border 
healthcare.  The  study  developed  some  practical  documents,  including  a  set  of  decision  trees,  to 
facilitate  NCPs  in  the  provision  of  information  on  both  the  Directive  2011/24/EU  and  the  Social 
Security Regulations.  

The  Guiding  Principles  aim  to  contribute  to  an  equitable  access  to  cross-border  healthcare  in 
different  ways.  NCPs  are  encouraged  to  make  sure  that  the  information  they  provide  is  easily 
accessible and understandable for all patients, regardless of their health literacy, sensory capacities 
or language. NCPs should provide information that is relevant to different types of patients, such as 
outbound and inbound patients, patients with disabilities, patients with rare diseases, patients with 

10 

 
 
Study on cross-border health services: enhancing information provision to patients  

limited funds, and patients who reside outside the MS of social security insurance. In general, the 
study output aims to contribute to a more uniform and equal practice of NCP service. Where great 
differences are shown in NCP practice and information provision, the Guiding Principles and toolbox 
aim to eliminate these differences and to establish the same, high level of service in all MSs. In the 
same way, the instruments aim to establish transparent and equal procedures for accessing health 
services in all countries.  

Bilateral exchange and NCP workshop 

This study found that NCPs are performing fairly well in general, but that there is still ample room 
for  improvement  on  specific  topics,  and  that  there  were  large  differences  between  NCPs  in  the 
current  level  of  information  provision.  For  both  the  different  categories  included  in  the  website 
analysis  and  the  different  scenarios  included  in  the  pseudo-patient  investigation,  NCPs  who 
performed very well were identified. This shows that there is great potential for NCPs learning from 
each other and helping each other improve their information provision to patients in the context of 
cross-border healthcare. 

Core finding 5: 
Overall,  there  is  still  ample  room  for  improvement  in  NCP  practices.  There  is 
especially great potential  for NCPs to  learn  from  each  other and help each other 
improve  their  information  provision  to  patients  in  the  context  of  cross-border 
healthcare.  

To  validate  the  findings  of  this  study,  as  well  as  the  toolbox  and  Guiding  Principles  that  were 
developed to assist NCPs in further improving their information provision, NCPs were consulted. For 
this  purpose,  bilateral  exchange  with  NCPs  took  place,  where  they  were  provided  with  their 
individual results and with the general toolbox and Guiding Principles. The aim was to gain as much 
feedback from NCPs as possible, in order to validate the added value for NCP practice of this study 
and  the  provided  toolbox.  Based  on  NCPs’  comments  and  recommendations,  the  project  team 
made  revisions  to  the  different  end  products  of  the  project.  NCP  consultation  and  validation  was 
also established by organising an NCP workshop in Brussels on 8 March 2018, which was followed 
by a final round of email consultation regarding the adjusted Guiding Principles.  

Methodological and practical contributions of this study 

Overall, this study contributes to the literature on information provision for patients in cross-border 
healthcare by providing a systematic analysis of the status quo, based on a triangulation of results 
from  different  data  collection  methods:  literature  review,  website  analysis,  pseudo-patient 
investigation,  and  two  surveys.  In  addition,  this  study  goes  beyond  the  existing  literature  by  not 
only  mapping  the  status  quo,  but  also  providing  a  toolbox  and  training  material  for  the  NCPs  to 
improve the quality of information provision to patients in cross-border healthcare. 

This  study  has  made  specific  methodological  contributions  by  refining  research  protocols  for  the 
website  analysis  and  pseudo-patient  investigation.  This  was  done  both  ex-ante,  based  on 
experiences  in  other  studies,  as  well  as  ex-post,  based  on  the  experiences  during  the  current 
study. These refined research protocols enable future studies to be conducted in the same way as 
this  study,  thereby  allowing  for  the  collection  of  information  on  the  same  variables  over  time.  In 
addition, the refined research protocols provide NCPs with templates for self-assessment. 

Another important  methodological  contribution  of  this study is the continuous communication and 
collaboration  with  the  NCPs  via  multiple  channels:  presentations  to  keep  NCPs  updated  on  the 
(progress of) the study, bilateral  exchanges (via email and telephone) to enable  enquiring  about, 
and  making  comments  on,  individual  results,  as  well  as  providing  feedback  on  the  toolbox  and 
training  materials,  and  a  workshop  to  jointly  discuss  the  results,  recommendations,  and  way 
forward.  

Some of the practical contributions this study makes to improving information provision to patients 
by  NCPs  are  the  Guiding  Principles,  the  toolbox  and  training  material  for  NCPs.  These  can  be 
considered as an important policy development in the field of information provision in cross-border 
healthcare, as they aim to establish a more uniform and high level NCP practice, where clear and 
accurate information provision to patients is central. 

Central  in  developing  the  Guiding  Principles  and  the  toolbox  was  the  goal  to  ensure  information 
provision  in  accordance  with  the  legal  requirements  placed  on  NCPs  and  healthcare  providers  by 
Directive  2011/24/EU,  as  well  as  to  ensure  equal  free  movement  of  all  patients.  As  long  as  this 
goal is achieved, NCPs are free to organise themselves according to their own insights and wishes. 

11 

 
Study on cross-border health services: enhancing information provision to patients  

All  instruments  have  been  validated  by  the  NCPs  themselves,  during  bilateral  exchange  and  the 
NCP workshop on 8 March 2018. In addition, the policy proposal instruments were developed based 
on already established NCP practice, in all EU MSs and Norway.1  

The  Guiding  Principles  aim  to  contribute  to  an  equitable  access  to  cross-border  healthcare  in 
different  ways.  NCPs  are  encouraged  to  make  sure  that  the  information  they  provide  is  easily 
accessible and understandable for all patients, regardless of their health literacy, sensory capacities 
or language. NCPs should provide information that is relevant to different types of patients, such as 
outgoing and incoming patients, patients with disabilities, patients with rare diseases, patients with 
limited funds, and patients who reside outside the MS of social security insurance. In general, the 
study output aims to contribute to a more uniform and equal practice of NCP service. Whilst great 
differences exist in NCP practice and information provision, the Guiding Principles and toolbox aim 
to  eliminate  these  differences  and  to  establish  the  same,  high  level  of  service  in  all  MSs.  In  the 
same way, the instruments aim to establish transparent and equal procedures for accessing health 
services in all countries.  

Methodological limitations 

While the study provides multiple practical and methodological contributions, it is also important to 
note that the approach used in the study suffers from some limitations.  

Website analysis: 

The website analysis was conducted once per NCP website, in July 2017. As also discussed during 
the  workshop  on  8  March  2018,  many  NCPs  are  continuously  improving  their  website  and  its 
content. Consequently, the results should not be considered a final judgement on the information 
provision  on  NCP  websites,  but  should  rather  be  seen  as  indicative  of  the  amount  of  information 
available for patients at the  time  of  the  study.  It  thus provides a valuable snapshot of the status 
quo, including elements that warrant improvement as well as best practices, thereby enabling NCPs 
to learn from each other.  

Each  NCP  website  was  analysed  by  only  one  researcher.  Therefore,  it  is  possible  that  some 
information  was  overlooked.  However,  the  research  protocol  was  designed  to  reduce  this  risk  of 
omission or oversight as much as possible; the researchers analysed each website thoroughly in a 
structured manner using a standard form. It is our belief that if information was overlooked by one 
of our dedicated and trained researchers, it is unlikely that this information is easily found by the 
average patient. 

Pseudo-patient investigation: 

Mystery shopping exercises have a limited sample size. As a result, this research method provides 
qualitative  rather  than  quantitative  insights.  In  practice,  comparisons  between  NCPs  should  be 
made  with  caution.  Our  findings  based  on  the  four  specified  scenarios  do  not  allow  for 
generalisations  across  all  cross-border  patients  and  scenarios.  Nevertheless,  the  pseudo-patient 
investigation  provides  valuable  insights  into  the  potential  obstacles  patients  encounter  in  their 
search for information regarding cross-border healthcare. 

In this exercise, email contact and telephone contact (if the NCP was reached) was used as a mode 
of  contact.  Personal,  face-to-face  contact  was  not  evaluated.  It  is important to  highlight  that  this 
could be presented as an option by the NCPs. However, in practice patients seeking information on 
cross-border  healthcare  will  generally  not  do  so  by  visiting  the  physical  NCP  address  (especially 
true  for  incoming  patients).  Additionally,  not  all  NCPs  provide  a  physical  address  as  a  contact 
option. Hence, this is merely a minor limitation of the study. 

Finally,  a  mystery  shopper  or  pseudo-patient  is  subject  to  their  own  preferences  and  habits.  This 
leaves  some  scope  for  personal  bias  to  influence  results.  This  potential  of  bias  was  minimised  by 
the extensive briefing of the mystery shoppers and the use of strong assessment tools. 

1   Only  detailed  information on the NCP practice of  one MS was missing. Information on this  MS was collected through the 
website analysis (Work Package 2) and the pseudo-patient investigation (Work Package 3). In total two MSs did not reply 
to the NCP survey, however, one of them provided the information gathered in the survey during the bilateral exchange by 
completing the document of its country specific description.  

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Study on cross-border health services: enhancing information provision to patients  

Patient survey: 

Due  to  the  limited  sample  size  (n=11),  it  was  not  possible  to  come  to  any  valid  quantitative 
conclusions  on  patients’  experiences.  Due  to  the  limited  sample  size,  robust  quantitative 
conclusions  and  generalisations  across  all  patients  in  planned  cross-border  healthcare  cannot  be 
made.  Rather,  the  results  of  the  patient  survey  should  be  considered  as  valuable  qualitative 
indications of user experiences. Due to data protection considerations, no personal data on patients 
were  collected,  hindering  the  possibility  to  ask  follow-up  questions  or  clarifications.  The  patients’ 
experiences retrieved through the survey are indirectly feeding the results and output of this study, 
i.e.  based  on  findings  of  previous  studies  and  published  reports  and  recommendations  of  the 
European Patients’ Forum (EPF).  

Due  to  the  combination  of  utilised  research  methodologies  (desk  research,  website  analysis, 
pseudo-patient  investigation,  and  online  surveys),  this  study  is  sufficiently  robust  and  provides 
strong evidence on the level of information provision by NCPs, despite the mentioned limitations. 

Recommendations for future research 

In  general,  in  order  to  evaluate  the  progress  of  information  provision  in  practice,  it  would  be 
valuable to repeat the current study at different points in time. Researchers would be encouraged 
to draw and build on  the same  research  protocols that were  updated  and  specified  in  the  current 
study.  In  this  way,  valuable  insight  into  the  evolution  of  information  provision  by  NCPs  could  be 
obtained.  

Further research on the specific needs of certain categories of patients in cross-border healthcare - 
taking into account amongst others disability, income and education level and gender – would also 
provide the European Commission, MSs, NCPs and other stakeholders with valuable information. 

In order to ensure that the proposed Guiding Principles, toolbox and training materials are indeed 
of added value for NCP practice and a contribution to enhanced information provision, the uptake 
of  the  instruments  and  their  functioning  in  practice  would  need  to  remain  a  key  issue  for  the 
future.  

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doi:10.2875/788651 
ISBN 978-92-79-80265-2