Spain and other nations blocked the draft proposal, we ask the experts why


The European Directive on cross-border healthcare has encountered more opposition as it goes through the process of ratification in the European Parliament. According to Dr Klein and Dr Constantinides, this latest setback is not unexpected. Both believe that while this action has not been welcome it does bring about an opportunity for the EU to take the Directive back to the drawing board and re-draft it.  They believe that the ratification process has highlighted many obvious and major flaws and limitations in the current draft directive and now is the time to start addressing the many issues that need to be considered to create a workable cross border health directive.

The view from Greece: Dr Constantinides

Dr Constantinides, why do you think Spain and other countries have opposed the Directive?

I think that Spain and other countries decision came about as a result of the individual Governments being rightly fearful of the potential logistical nightmare that would come about as a result of a poorly thought out system. They probably realised that certain elements have to be in place for the Directive to work and that those elements are not there and the draft Directive as it stands is currently full of gaping holes which need to be addressed before it can be ratified.

I think that those bureaucrats and academics who drafted the Directive failed to do their homework and therefore failed to address the issues of concern and in doing so failed to provide practical and universally acceptable solutions that could make this work. It has been badly thought through and hopefully this will get the drafters back to the drawing board.

Until now, I don’t think a lot of individual countries really wanted the Directive and have been paying lip service to Brussels because it has been politically correct to do so. Now these countries have had a chance to really consider their own interests they have realised that implementing the directive as it stands is untenable.

The main issue is what is next. The issue will come up in Venice at the forthcoming European Medical Travel Conference in May 2010 where there will be an opportunity for industry members to look at the Directive and pick out the fundamental principles and translate them into practical implementable principles. These issues have not yet been worked through or resolved and without the support of all the member states there won’t be legal certainty and the Directive won’t work.

What do you think are the main issues and elements that are missing from the Directive?
There are three main areas of serious practical concern that need to be addressed in order for the cross border health care to work properly.

At healthcare cybernetics we have identified the three major areas of serious concern that have not been covered by the original Directive. Ever since I participated in the 2006-2007 EU Commission Consultation I have been pointing out “the issues of concern” which unless understood and addressed will prevent the Directive from working.   (Read hCc’s contribution to the Consultation).

Firstly, there is the vital issue of financial and administrative management of imbalanced patient flow.  There is no doubt that certain counties will be more popular with inbound patients than others which will have both short and long-term implications both financially and administratively on unrestricted patient mobility, systems need to be put into place to manage the effects of this.

Secondly is the question of financial responsibility and reimbursement – and of course, a common pricing and e-billing structure. While all countries have adopted this “in principle” few have actually implemented it in practice. In practical terms this means that countries that don’t use DRG (Disease Related Group) coding, and other coding and eHealth practices, will not be able to participate in the patient mobility/health insurance portability scheme.  I believe that it is imperative for an EU-wide survey to be conducted to determine which healthcare facilities are DRG and e-billing compliant and thus can participate in the scheme.

Another crucial element is the availability of an EU-wide interoperable electronic health information system.  With the announcement this week that the NHS is cutting £12m from its IT budget it looks like the NHS will not be e-health compliant. This is an example of how the Directive cannot work if there is no standardised / interoperable eHealth System in place – for all participants to use. And let us not forget that cross-border health is not “Language Neutral” – what language would be used to record “narrative information” in the eHealth Record? - (and I am not referring to Communication Protocols and “Nomenclature”).

Lastly, patient safety is an element which needs to be considered. This covers responsibility for the travelling patient, hospital accreditation, safety records, doctor qualifications etc. At hCc we advise that the authorities in the EU member states involved in cross border healthcare to collaborate to compile an constantly updated database of assessed and approved healthcare facilities and providers so that patients, all healthcare authorities and referring physicians can refer to information check online before making decisions about treatment.

The view from Germany: Dr Uwe Klein

Dr Klein, what do you think might happen as a result of the blocking of the Directive by these countries?

Well, as we know, the right for Europeans to travel within the EU is enshrined in EU law and the point of the Directive is to remove any legal barriers preventing patients from travelling and to provide a framework and structure for this process.  If this issue cannot be resolved with the countries that wish to block the Directive I think the best way forward is for the European Courts to overrule this decision.  In addition to the courts getting involved patients need to be informed and educated about their rights and they need to know that the European courts will protect their individual decisions to travel within the EU for treatment.

If the EU ultimately does fail to deliver a Directive that is accepted by all countries, I believe we will see healthcare providers working together with patients in both the private and public sector to help them get the help and legal assurances they need to get the treatment they want if they are blocked from travelling by their own countries.

Additionally, Government groups in certain countries might assist patients to help them travel for treatment, for example, it is possible that the governmental institutions might help to set up a good infrastructure for foreign nationals coming to Germany for treatment.. 

What do you think is needed to move this forward?
I think the EU listens to people with a brilliant generic and necessary administrative way of thinking whereas the private sector is more solution orientated and combines commercial practicalities and realities with patient needs, which is why we need a dialogue.  What I am trying to achieve with the EMTC conference in Venice in May next year is to encourage a productive dialogue between the public and private sector. Of course the success of the conference and what we are able to achieve depends on the openness of the European institutions and the industrial players as well.

What is interesting is that many people throughout the EU are aware of the problem so it is vital that a workable solution is found.  Within the next five to ten years, the healthcare systems of Western Europe are in some cases predicted to collapse under the financial burden, especially the state run systems.  I believe that it is not too late to start finding solutions.  For some of them Medical Travel might be an option to restructure their systems without loosing care quality for their nationals. 

So what do you should happen next?
The new Health Commissioner designate John Dalli, is going to have a tough job to integrate what is left of the Directive.

The EU bodies and Ministers of Heath should work together with the industry to find solutions.  They should come to the conference in Venice to have a closer look at industry solutions.  Dr Bertinato, head of international and social affairs of the public health in Veneto is convinced that the solution lies in Government ministers and the EU working closer with the private accredited sector for finding the right answers to still open questions of patient safety, reimbursement and treatment quality standards.
Dr Bertinato from the Veneto Health Region

The view from Italy: Dr Bertinato 

Dr Bertinato, Head of International and Social Affairs, Public Health, Veneto provided his views on the situation relating to the EU strategy debate which was blocked due to the opposition of some Member States:

“We understand the preoccupation of the Spanish authorities which is linked to the economic sustainability of  the impact of the huge number of pensioners travelling to southern Spain for long periods in the winter season, who make extensive use of local health facilities
with additional services, but without acquiring prior authorization. Reimbursement of their costs can only be made with great difficulty and is subject to a lot of red tape.

For the Veneto Region of Italy with its 14 million tourists a year we think that the strategy of developing bi-lateral agreements with German health insurance companies can be a viable method of working in this transition period of time, where patient mobility in the EU is shrouded by a host of legal uncertainties.

The result of the block on the European Directive will be an increase in the use by  European patients of the European Court of Justice.  After winning their cases, these patients would probably obtain the same authorizations to be treated abroad with the added compensation.

We believe that the right of citizens to free movement in the EU and the empowerment of the patient using the internet and a proper dissemination of information have to be considered the most important challenges for all health care systems, in order to respond effectively and quickly to their needs.

The need for a new EU Directive on patient mobility should be underlined in order to enable:

  • equal opportunities to access health care systems in the EU;
  • a good quality of health services which take into account patient safety and the proper follow up of patients after medical treatment abroad.

No doubt there is a huge space for a European debate.”


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