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Does the EU need a Health Services Directive?


Speech by Proinsias de Rossa MEP to the European Nursing Students Association
Dublin, 6 July 2007

A 2005 Eurobarometer survey indicated that by a 2-1 majority, Europeans believe Europe outperforms the US when it comes to healthcare. After environmental protection, healthcare is the main area where the 'European way' is seen as preferable to the 'American way'.

While there is no single European health system, our health services constitute a major part of the European Social Model. Health systems make an important contribution to social and territorial cohesion and there are obvious economic benefits in having a healthy population.  Health services generally are underpinned by the basic EU principles of equality of access, universality, equal treatment and solidarity as well as affordability and financial sustainability. This is recognised by Article 35 of the European Union's Charter of Fundamental Rights which provides that everyone has the right of access to preventative health care and to benefit from medial treatment.

The European treaties respect the exclusive responsibility of Member States for organizing, managing, delivering and financing their health care systems. That said, the treaties do commit Europe to a 'high level of health protection'. They recognise that European coordination can assist national policies.

On this basis, at the plenary session in Strasbourg (9th-12th July), the European Parliament is set to approve the EU's €366 million Public Health programme for 2008-13. This will concentrate on improving protection from cross-border health risks, promoting action at national level on nutrition, alcohol, tobacco and drugs, boosting cooperation between national authorities, and helping health systems learn from each other.

Against the background of common challenges such as developments in medical science and the aging of the population, a consensus has emerged on the merits of closer cooperation on health between Member States. A formal system of structured cooperation, involving information exchanges, peer reviews and the comparison of national policies, has been put in place, initially for issues such as continuing professional development and creating European centres of references. This structured cooperation could however be much more effective in driving non-legislative change if it were subject to greater parliamentary scrutiny, especially at national level. It is clear as the EU Health Commissioner Markos Kyprianou said recently, the 'European dimension of health is maturing rapidly'.

The impact on health services of other European policy developments, particularly competition, environmental, enterprise, and internal market policies, is assuming greater significance. Since 1998, a number of European citizens have successfully used the European Court of Justice to vindicate their right to seek health services in other countries under EC internal market rules.  In a number of very significant judgments, the ECJ has concluded that:

Any non-hospital care to which a person is entitled in their home country, they may also seek in any other EU country without prior authorisation;
Any hospital care to which a person is entitled in their home country, they may also seek in any other EU country subject to prior authorisation by their home country. This authorisation must be given if their system cannot provide them with care without undue delay considering their condition.
Crucially in both cases, costs are reimbursed to the level provided by the home country.

These so-called patient mobility rulings are clearly good news for patients in need of urgent treatment which they cannot access at home and who are able to 'move'.  One positive aspect of these rulings is that the decision on whether a person should seek health care elsewhere is down to a health professionals' view on the urgency of a procedure, not an official waiting list target. But I believe that we cannot allow our health services to be dictated by ECJ interpretations of internal market rules. Such an approach would lead to the creation of an internal market in health services, competing on the basis of costs, leading to a damaging leveling down of quality of care and creating a two-speed health system where only the better off and better informed patients would benefit. Whatever their level of income or place of residence, everyone in Europe must be guaranteed equal and affordable access to health care when needed, in accordance with the principles of universality, quality, safety, continuity and solidarity.

There is therefore a need to set down the parameters for health service standards in Europe and to clarify the implications of ECJ rulings in a European Health Directive. Such a Directive must address:

the practical problems that arise for patients who wish to seek healthcare elsewhere;
how can patients and healthcare professionals identify, compare or choose between providers in other countries;
the retention of the flexibility Member States need to plan their own systems, without creating unjustified barriers to patient mobility;
how can compensation mechanisms be put in place for 'receiving' countries;
The impact on related services such as social services and long-term care, which in the vast majority of cases will be required near 'home';
The discrepancies in ECJ terms such as 'undue delay' and the distinction between hospital and non-hospital treatments - for example, does hospital care, for which prior authorisation is required, include treatment provided in a doctor's surgery or in a medial centre?;
The need to guarantee the legal security of patients and of professionals.
European policy initiatives relating to health services should be made by the parliaments of Europe, both national and European, not on an ad hoc basis from rulings of the Court of Justice.

The previous Internal Market Commissioner Frits Bolkestein and his successor Charlie McCreevy originally sought to address health services issues in their draft Services Directive. Including health in legislation designed to create an internal market in commercial services was one of the most controversial aspects of that original proposal and one which led to its wholesale rejection across Europe.

In February 2006, as part of its complete overhaul of this controversial proposal, we successfully excluded health from the scope of the directive. The national Ministers, some more reluctantly than others, were subsequently obliged to accept this outcome. Nursing organizations such as the INO and their counterparts all across Europe played a very significant role in this success.

On 23 May 2007, the European Parliament adopted a resolution on the implications of the exclusion of health services from the 'Services Directive'.

While I regret that the EP declined to take up Labour's and the Socialist Group's call for a specific health services directive to deal with these consequences, I do welcome its decision to urge the Commission to come forward with an 'appropriate instrument' to codify the case law of the European Court of Justice on patient mobility. I believe such an instrument should be a directive and I will continue to campaign for such a directive in the EP.

I also believe that there are a number of additional issues to be addressed.

The right of health-care professionals to move throughout the EU should be improved and there is need to better inform health care professionals of their right to move around the EU, perhaps by making better use of existing EU tools such as the European Employment Services (EURES). At the same time patients need to be protected from people peddling bogus qualifications.

Health-care professionals should also be able to access a standard European card outlining their professional qualifications with a view to improved trans-national systems of continuing training.

Under the 'Lisbon Agenda', Europe has set itself the ambitious target of becoming the world's most competitive, knowledge-based economy and socially-inclusive, jobs-rich society by 2010.

A healthy active population obviously plays a key part in achieving these goals. Investment in health is therefore being stepped up under the 2007-13 structural funds and under Europe's research programmes.

In June 2005 and again last May, the European Parliament emphasized that European policy on healthcare has to be based on the common values of universality, access to good quality care, equality of treatment and solidarity.

Good work along these lines is being done within the Council of Health Ministers by a caucus group of (mostly social democratic) Health Ministers with the objective of ensuring that the market approach does not predominate.

I would add that the European Constitution proposed making the promotion of 'the well being of its entire people' one of the Union's fundamental aims. The Inter-governmental conference which will convene on 23 July to agree the new 'Reform Treaty' by the end of the year must carry over these particular provisions. It must also ensure that the Charter of Fundamental Rights, which includes the right to healthcare, is legally binding and fully applicable the EU and particularly in Ireland

National governments retain primary responsibility for health policy and will continue to do so. But we are also likely to see an increasing role by Europe in health matters.

Whether this result in better public healthcare for patients or in the privatization and fragmentation of services depends on the degree to which citizens, healthcare professionals, healthcare providers and public representatives engage with the process. In short, political choices by national and European politicians have a bearing on outcomes and it is therefore essential that those working as health professionals engage with us to ensure that all aspects of what is a specialized area are taken into account.


There is a need for a Health Services directive to ensure that the coordination of health services is not driven by market forces but by patient care.

There is too a need for a European Patient Safety Agency which would ensure common, high level standards of treatment and safety for patients across the EU.

Both outpatients and hospital patients also need to be protected against counterfeit medicines, that is, illegal products masquerading as 'medicine' which not only does not offer any relief to a patient but can put their health and life at risk.

We must ensure that the European approach to health policy is firmly rooted in Europe's common values and not in an approach which mistakenly dictates that market forces are necessary for delivery of quality services. The vast majority of Europe's citizens do not want the 'US model' of health service delivery which serves less than half the population. Bodies such as the European Student Nurses Association are very well placed to set a more progressive agenda than that.

I look forward to working with all concerned to ensure that the results of the deliberations over the coming year are better health services all across Europe.

Thank you.