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PV 12/03/2007 - 22
CRE 12/03/2007 - 22

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PV 15/03/2007 - 5.2
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Pirmadienis, 2007 m. kovo 12 d. - Strasbūras Atnaujinta informacija

22. Bendrijos veiksmai kelias valstybes apimančios apsaugos srityje (diskusijos)

  El Presidente. El punto siguiente es el debate sobre la pregunta oral a la Comisión sobre la acción comunitaria relativa a la prestación de servicios sanitarios transfronterizos, de Karl-Heinz Florenz, en nombre de la Comisión de Medio Ambiente, Salud Pública y Seguridad Alimentaria (O-0001/2007 - B6-0013/2007).


  John Bowis (PPE-DE), deputising for the author. – Mr President, I very much welcome this debate and the progress that is going to be made following the ECJ judgments, and I know that the Commission has this in its sights.

When I was in Potsdam in January for the German Presidency’s first health conference, I very much welcomed the German Government’s encouragement and its determination to see progress on the issue of patient mobility. We now look forward to the Commission taking that ship into the seas and bringing it safely to harbour for the benefit of our citizens.

In Potsdam, I quoted Jean Giraudoux, because we have a problem, and his quotation, I thought, symbolised it. He said ‘

Jamais poète n'a interprété la nature aussi librement qu'un juriste la réalité.

Mr President, no poet ever interpreted nature as freely as a lawyer interprets the truth. And, with apologies to any lawyers who may be listening, it is a fact that the lawyers of Europe are deciding policy on patient mobility. Why? Because the politicians of Europe have failed to do so.

If you are happy with unelected lawyers deciding national and European Union health policy, then you do not need to do anything. Just wait and the bills will come in. But if, like me, you believe that it should be the job of parliamentarians, then we need to get on and give legal certainty and guidance without further delay in this whole area for patients.

But we need not panic. We are not talking about vast numbers. Most of our citizens prefer local options and, of course, language may be a deterrent to travelling very far. Only if we have waited too long are most of us interested in cross-border healthcare. Our preference is that local provision will improve and make patient mobility unnecessary and that, in a way, would be a good outcome of the ECJ judgments in itself. But we want to know how the new system will work in practice in case we need it.

We are not talking about a pan-European health service. We are talking about new powers for the patient to bypass sluggish and inadequate services locally and nationally. But, without clarity, without systems, without guidance, we are going to see major concerns as patients and their medical advisers seek to find their way through the complexities of the system, and health budget holders are in chaos as they try to cope with totally unpredictable demand for service funding.

So, as patients, as doctors, as managers, we need answers to some basic questions. The questions the patient asks are: Do I qualify? What is undue delay? Are there differences between conditions and between individuals, including the age of the individual? How do I apply if I need to? How do I or my GP decide what my options are? What country, what hospital, what specialist? What aftercare? Can I top up if the price is higher than in my home Member State? Who decides if the type of treatment complies with the new criteria? And I need to know before I go, not find out later. And how do I appeal if I disagree with the decision? Or do I have to go to court each time? Who will have access to checks on professionals? How will patient records be exchanged? Who pays for my travel, and for that of an accompanying person if I am a child? What channel for complaints is there if something goes wrong? How will reimbursement be affected? What will be the international interface between different systems, Beveridge/Bismarck, euro/non-euro zones? Do we need a central clearing house for claims and payments, nationally or for Europe? And lastly, is my mental illness also covered?

We shall need European legislation for some of these answers and national legislation for others. But above all we shall need guidance to provide clarity for patient and practitioner alike. We shall need to test the water and adapt to experience, such as with centres of excellence. We need to speed ahead with our frameworks for health professionals and patient safety and sort out the E121 system for people retiring abroad.

People have voted with their challenges to the courts and the ECJ has responded and confirmed their rights. Now we need political action to put in place a system which will be welcomed by people as a benefit coming from Europe.


  Markos Kyprianou, Member of the Commission. Mr President, I am not sure whether I can say that we have come a long way since we first discussed this issue, but I can certainly say that we are on the right track. You will remember that our first discussion on this issue was even before the final outcome of the Services Directive. Parliament requested that a proposal on healthcare and health services should be brought forward and I promised that, as soon as the Services Directive was sorted out, I would do so. That is what I did last September in bringing forward this proposal.

Many issues have been described already and I will try not to repeat them. However, we tried to maintain, firstly, the special character of health, healthcare and health services in the European Union and to meet the challenge not only of achieving the social objectives, but also of benefiting from the internal market. It is true that the Court set out the parameters and the rights in its judgment, but I believe that those rights should be seen not as a problem, but as an opportunity and I tend to agree with that part of the motion for a resolution.

We have the realities before us, as described by the European Court of Justice. The point now is how to make them work for the benefit of patients, the Member States, national health systems and providers. We can do this not only for patient mobility, but also for all other aspects of cross-border healthcare.

I agree that the ultimate target must be that a European citizen should be able to receive the best healthcare where he or she lives. We should meet our aim of ensuring equality of health in the European Union. However, we know that this is a long-term objective and also that, under certain circumstances, it may not be possible, feasible or even desirable, depending on the financial, as well as – most importantly – the scientific aspects. Sometimes, we will still need to make use of the cross-border possibilities of healthcare.

As I have said, we launched the initiative in September 2006. The idea was to have a broad consultation, which ended on 31 January 2007. In the communication we described and analysed all the problems and issues, which are complicated. We have to follow a step-by-step approach. We will need a package to sort out and deal with all the aspects of cross-border healthcare, but that does not mean that we have to wait until they are all resolved before we present a proposal: we can do that in phases.

We are now in the process of analysing the contributions. We have had more than 270 from the Member States, from regional and local authorities, and from European national and regional organisations, representing patients, healthcare providers, health professionals, social security institutions, health insurance, universities, and hospitals, and even from individual citizens. Although I do not want to prejudice the results of the in-depth analysis, it must be said that the first assessment confirms the need for Community action to address the range of issues set out in the consultation paper, for example, legal certainty and support for cooperation between health systems. In addition, even though there are many different views on the details of specific aspects, the overall picture is clear: there seems to be potential added value for patients, professionals and health systems overall from some form of Community action on health services.

The Commission is in the process of analysing a summary of the report on all the contributions already published on our website. A summary report of the contributions will be drafted to provide an idea of the views and ideas sent in and should be available this spring.

However, the views and the input of the European Parliament are extremely important to us and will be a determining factor.

We will ensure that any future proposals on health services under this initiative are consistent with ongoing work on services of general interest and, of course, on the ongoing modernisation of the regulations on the coordination of social security systems. There has to be coherence and coordination among all these initiatives.

On the basis of the consultation and its outcome, the Commission plans to bring forward practical proposals later in 2007. Our aim is to find a solution which provides real added value without creating more red tape and which respects the principle of subsidiarity.


  Françoise Grossetête, au nom du groupe PPE-DE. – Monsieur le Président, Monsieur le Commissaire, nous nous souvenons tous des débats que nous avons eus dans notre Parlement, lors de la discussion sur la directive sur les services, pour exclure les services de santé. Nous estimions en effet que la santé n'est pas un service comme un autre et qu'il était absolument indispensable d'en parler autrement et surtout de ne pas penser les services de santé uniquement comme un marché intérieur.

L'Union européenne, par ses politiques, encourage la mobilité des personnes et cela a forcément des conséquences en ce qui concerne des soins de santé. Cela a des conséquences bien sûr pour les professionnels de la santé, qui ont des exigences au niveau de la sécurité juridique, et bien sûr pour les patients, qui sont désireux de recevoir des soins de qualité. D'où un certain nombre de problèmes, comme l'a relevé mon collègue M. Bowis: des problèmes de langue, le problème de suivi des soins, le problème de la responsabilité des professionnels de santé, de la qualité des soins. J'estime qu'il est important de dire que la mobilité des patients ne doit aucunement entraîner de dumping des systèmes de santé, ni dégrader la sécurité des soins de santé. C'est absolument fondamental.

La mobilité des patients et des professionnels de la santé ne doit pas non plus créer deux catégories de patients: ceux qui pourraient accéder à d'autres types de soins de santé de l'autre côté des frontières et ceux qui ne pourraient pas le faire. Il serait donc intéressant de développer davantage des indicateurs harmonisés de santé au niveau européen. Il en va de même de la réalisation d'études plus exhaustives pour mieux appréhender les besoins locaux et davantage cibler les publics susceptibles de se faire soigner dans un autre État membre, afin d'apporter la solution législative la plus adaptée. Pour cela, il faut un mécanisme de collecte des données et d'échange d'informations entre autorités nationales.

In fine, il convient d'être très vigilant quant aux dérives actuelles concernant l'autodiagnostic, l'automédication via Internet qui ne connaît pas de frontières. Il devient urgent de se préoccuper de l'information des patients et d'avoir un véritable label européen afin d'assurer aux cyberpatients une sécurité et une information viables. Monsieur le Commissaire, sachez que vous aurez tout notre soutien et notre confiance pour la proposition que vous nous ferez prochainement.


  Linda McAvan, on behalf of the PSE Group. – Mr President, Commissioner, you know from our discussion in committee that this issue is extremely important for myself and for the PSE Group. We see health services as one of the pillars of the European social model, and the underlying values of that model – universality, access to good quality care, equity and solidarity, to ensure that services are provided on the basis of need and not the ability to pay — are fundamental to us and to that model. We feel that any initiative you take on cross-border healthcare should be built on these principles. It should be about healthcare for all and not about market opportunity for some providers. I think many other colleagues from different groups have already said this.

Mr Bowis talked about the legal certainty that is needed in a range of areas. These are the questions that people write and ask me about. They have heard about their rights, they are not sure how they can exercise them, so yes, we want a clear legal framework for patient mobility and for the movement of professionals, not just to give them rights, but so that citizens know that those healthcare professionals are properly qualified, are fit to practise and that information is shared between Member States.

Finally, Commissioner, you said that you recognised that healthcare has a special character. The health ministers agreed a set of values and principles in June last year, and I wonder whether you will be taking that on board when you draw up your proposals later this year?


  Antonyia Parvanova, on behalf of the ALDE Group. – Mr President, we strongly support the Commission’s consultation efforts and the European Parliament resolution outlining the main priorities for public health in the future Community framework. But we should think and plan more broadly: the final goal of future legislation should be better health for European citizens, not only when they cross the border, because by then it might be too late.

In addition to the resolution, I would like to call for your support on the following: basic standards for healthcare should be agreed in order to guarantee patients’ safety and the quality of healthcare; the introduction of a common classification of health services, without interfering with Member States’ competences on organisation, will create transparency for both patients and the financial institutions; and the ‘one-stop shop’ approach to be introduced in the Member States’ health administrations will facilitate patients’ choice and the right to complain.

The last issue I wish to emphasise is crucial for the full functioning of any new legislative framework on patients’ rights: a common charter on patients’ rights should be included in the future Community framework. Patients should be able to exercise their rights in the European Union regardless of the ownership of medical facilities, national social security schemes, organisational management of the national health systems or whether medical treatment is provided in the home country or in another Member State. All this is needed for a new European regulatory healthcare framework that would contribute to improving access to the best quality healthcare and to ensuring the safety and rights of all public and private patients in Europe, with particular consideration given to ethnic minorities – for example the Roma population – as well as refugees, migrants and the homeless.


  Kartika Tamara Liotard, namens de GUE/NGL-Fractie. – Commissaris, het is op zich goed dat er wordt nagedacht over grensoverschrijdende patiëntenmobiliteit. Patiëntenmobiliteit is echter iets totaal anders dan mobiliteit van commerciële gezondheidsdiensten. Te vaak worden beide zaken door elkaar gehaald.

De discussie over patiëntenmobiliteit mag in geen geval leiden tot de ondermijning van de nationale gezondheidsstelsels of tot het afschuiven van verantwoordelijkheden door de lidstaten om te zorgen voor kwalitatief en kwantitatief goede gezondheidszorg in de lidstaten. Evenmin mag het leiden tot liberalisering van de gezondheidsmarkt of mag het patiënten dwingen om buiten hun eigen land voor zorg te móeten gaan.

Patiëntenmobiliteit is een recht van de patiënt en mag zeker niet het excuus worden voor het alsnog toepassen van de dienstenrichtlijn op de gezondheidsdiensten. Dit Parlement heeft zich zeer duidelijk daartegen uitgesproken en maakt zichzelf ongeloofwaardig als het nu een ander standpunt in zou nemen.


  Urszula Krupa, w imieniu grupy IND/DEM. – Panie Przewodniczący! Mając jedną minutę w dyskusji na temat transgranicznych usług zdrowotnych mam okazję jedynie powiedzieć, że oprócz rzeczywistych korzyści dla pewnej grupy pacjentów, którzy mają możliwości wybierania sobie terapii w różnych krajach Unii, niestety istnieją bardzo negatywne skutki dla niektórych systemów opieki zdrowotnej, ale też dla wielu chorych pochodzących z ubogich państw Wspólnoty, którzy pozbawieni są dostępu do służby zdrowia z powodu emigracji lekarzy lub ze względów ekonomicznych.

Priorytetem starych i bogatych państw Unii jest zwiększenie rozwoju, konkurencyjności i zabezpieczenia własnych systemów medycznych określanych jako „europejskie” bez zwracania uwagi na koszty, jakie ponoszą inne, o wiele biedniejsze kraje. Nie sposób nie zauważyć, że zwłaszcza ci, którzy są bogaci, stają się jeszcze bogatsi i bezpieczniejsi, natomiast biedni coraz biedniejsi, co dodatkowo określane jest zrównoważonym rozwojem, równymi szansami i równouprawnieniem albo zasadą pomocniczości, która dla obywateli europejskich ma wypaczony kierunek - słaby wzbogaca silnego, a biedny bogatego.


  Irena Belohorská (NI). – S ľútosťou musím konštatovať, že spomínané oznámenie Komisie v oblasti zdravotníckych služieb považujem za neuspokojivé. Okrem toho, že Komisia nám nedáva žiadne uspokojivé a konkrétne návrhy, ako chce poskytovanie zdravotníckych služieb koordinovať, keďže poskytovanie je vo sfére národných štátov, oznámenie tvrdo obhajuje pozíciu, že zdravotnícke služby sa majú riadiť princípmi slobodného pohybu tovaru.

V tejto súvislosti chcem zdôrazniť, že pacienti nie sú totožní s tovarom a zdravotnícky personál nie je totožný s ostatnými poskytovateľmi služieb. Za tento princíp sa Európsky parlament zasadil už vtedy, keď boli zdravotnícke služby vyňaté zo smernice o službách. Napriek tomu, že cezhraničná zahraničná starostlivosť predstavuje len okolo 1 %, oznámenie Komisie sa sústreďuje na mobilitu pacientov, preplácanie úkonov a podobne. Treba si však uvedomiť, že pacient nie je živnostník a nehľadá zdravotnú starostlivosť kvôli tomu, aby ušetril, ale hľadá ju preto, že mu nemôže byť poskytnutá doma. Preto jediný právny základ, článok 95, ktorý upravuje slobodný pohyb tovaru, je ako právny základ budúcej smernice alebo nariadenia absolútne neakceptovateľný.

Komisia by sa mala zamerať na iné problémy, ktoré v Európskej únii existujú, napríklad, čo spôsobuje, že úmrtnosť na rakovinu hrubého čreva je o 40 % vyššia na Slovensku ako vo Švédsku, sústrediť sa na to, ako môže Európska únia prispieť k zlepšeniu kvality zdravotníckych služieb, napríklad ako efektívnejšie použiť prostriedky zo štrukturálnych fondov na zdravotnícke účely.

Želám si, aby sa pacienti vedeli spojiť so zdravotníckym personálom a presadiť zmeny tak efektívne, ako to vedia napríklad poľnohospodári, aby konečne profitovali nielen farmári a dobytok, ale aj ľudia – pacienti.

Komisia zároveň upriamuje pozornosť na prijímajúcu krajinu. V tejto súvislosti chcem upriamiť pozornosť aj na vysielajúcu krajinu. Vo východnej Európe sa začínajú vytvárať tzv. biele diery ako nedostatok zdravotníckych pracovníkov.


  Charlotte Cederschiöld (PPE-DE). – Herr talman! Först vill jag tacka miljöutskottet för att ni har ställt denna utmärkta fråga till kommissionen som ger tillfälle att få höra kommissionens reaktion på viktiga frågeställningar. Det ger också oss från inre marknadsutskottet tillfälle att framföra det vi tycker är viktigt. Hälsa tillhör medlemstaternas behörighet och subsidiaritetsprincipen råder. Det är dock inte samma sak som att medborgare inte har rätt till hälso- och sjukvård i andra medlemsstater. Vi kan inte hävda att vi försvarar patientens rätt till säker och högkvalitativ vård om vi inte låter dem som så behöver, av en eller annan anledning, också söka vård i en annan medlemsstat. Vi måste göra vårt yttersta för att bevara dessa rättigheter, trots de olika dimensioner som alla här inne är så väl medvetna om att finns – problem, men också positiva dimensioner, i synnerhet på informationssidan.

Det är också uppenbart – eller borde i varje fall vara uppenbart – att EG-domstolens jurisdiktion inte kan försvagas av sekundärlagstiftning. Praxis finns, och fördraget ger varje medborgare som så önskar rätt att tillhandahålla tjänster i en annan medlemsstat, nota bene helt i enlighet med respektive lands lagar. Kommissionen bör som jag ser det dra tillbaka varje lagstiftning där medlemsstaterna och regeringarna försöker begränsa existerande primärrätt för patienter eller tjänstetillhandahållare. Det är viktigt att det förslag som kommissionen kommer med är ett steg framåt och inte ett steg bakåt och vi hoppas mycket på kommissionär Kyprianou i det avseendet.


  Bernadette Vergnaud (PSE). – Monsieur le Président, Monsieur le Commissaire, mes chers collègues, les services de santé, exclus de la directive sur les services, constituent un pilier essentiel du modèle social européen. Ils participent à la cohésion sociale, territoriale, économique, relèvent d'une mission d'intérêt général, tout en s'intégrant dans la stratégie de Lisbonne.

La consultation de la Commission ne saurait se réduire à la libre circulation des services de santé, ni viser à la simple mise en place d'un marché intérieur de ces services, qui conduirait à un système à deux vitesses, dont seuls les patients aisés et les mieux informés tireraient bénéfice.

Elle doit être l'occasion de définir clairement le rôle et la valeur ajoutée de l'Union, pour assurer un niveau élevé de protection de la santé dans le respect des spécificités nationales et des compétences des États membres.

La mobilité des patients et des professionnels doit être assurée dans le respect des valeurs et des principes fondamentaux suivants: universalité, solidarité, qualité, sécurité, durabilité.

L'adoption d'un cadre législatif européen, notamment une directive sur les services de santé, est de la plus haute importance pour renforcer la protection juridique des patients, des professionnels de la santé, des systèmes d'assurance maladie et ainsi redonner confiance à l'ensemble des citoyens européens de tous les États membres.


  Thomas Ulmer (PPE-DE). – Herr Präsident, Herr Kommissar, sehr geehrte Kolleginnen und Kollegen! Gesundheit ist grenzenlos — hoffentlich! Gesundheitsdienstleistungen sollen genau so grenzenlos, d. h. für jeden Unionsbürger in hohem Qualitätsstandard überall verfügbar sein. Wir sind jetzt am Beginn einer Diskussion, und nicht am Ende, und insofern ist eine kontroverse Diskussion zielführend und erwünscht. Gesundheit ist keine Ware, und der Binnenmarkt ist ja lediglich der Raum, in dem diese Dienstleistungen stattfinden.

Diese Dienstleistungen bedürfen einer besonderen Regelung, bei der die Fragen der Qualitätssicherung seitens der Anbieter, der Patientensicherheit, der Medikamentensicherheit, der Produktsicherheit der Medizinprodukte, der Frage der Regresse im Misserfolgs- oder Fehlerfall sowie die Frage der centers of excellence einer intensiven Prüfung bedürfen. Der Patient, den es zu schützen gilt, genießt besondere Beachtung, da er im Zweifelsfall der Schwächere, ja oft sogar der Ausgelieferte ist.

Wir befürworten grundsätzlich die Patientenmobilität und die Mobilität der Anbieter. Das reimbursement hingegen, das ein sehr wesentlicher Faktor im grenzüberschreitenden Verkehr von Gesundheitsdienstleistungen ist, ist jedoch subsidiär, und auch wenn es sich hier um eine frühe Phase handelt, gilt es, dies bereits jetzt klarzustellen.

Die 27 unterschiedlichen nationalen Systeme haben allesamt Probleme, und so sehe ich momentan keine Chance für eine europäische Krankenkasse. Ich halte eine solche auch nicht für zielführend. Auch hier handelt es sich im Bereich des reimbursement nicht um einen offenen Markt, sondern um staatlich-dirigistische Systeme.

In meinem Heimatland mit seinem außerordentlich komplexen System der Bezahlung der Leistungsempfänger würde sich bei einer Öffnung sofort die Frage der Inländerdiskriminierung stellen, da die Leistungen nicht offen, sondern gedeckelt bezahlt werden.

Ich halte es weiterhin für zielführend, dass die Hauptverantwortung für dieses Dossier beim Ausschuss für Umweltfragen, Volksgesundheit und Lebensmittelsicherheit und nicht beim Ausschuss für Binnenmarkt und Verbraucherschutz liegt.


  Markos Kyprianou, Member of the Commission. Mr President, I would like to thank Members for a very interesting debate, which will be very useful and will provide guidance for us in the next steps of drafting a proposal, along with the outcome of contributions from the other stakeholders, from consultations and from the Member States.

Just to cover a few issues: first of all, we will certainly be taking into account the health objectives and social values adopted by the health ministers last June, and this will be one of the considerations in our proposal.

At the same time, we will also be looking at the important issue of patients’ rights, which is part of our consultation on Community action. It is clear that we will look at these issues; what tools will be used will, of course, be decided after proper analysis of the consultation and based on the responses provided.

I would like to confirm that what we plan to do is to take a step forward and not to reduce or undermine patients’ rights as recognised by the Court, but to improve them and make them work, make them more concrete, and to make it possible to apply them equally among all European citizens. Information is an important factor in this respect.

As we have already stated, we will take subsidiarity into account. However, I have to remind you first of all that we do not propose harmonisation of national health assistance – this is not the intention. But, at the same time, I have to remind you of the European Court of Justice judgment on the Watts case, which provided that there are situations where Member States, based on other Treaty provisions, will have to apply to amend and adjust their national healthcare systems.

Finally, I think there is a misunderstanding here. First of all, there are no proposals in the communication because it is precisely a consultation document. We did not want to pre-empt the positions of Parliament, the Member States and the stakeholders, so it is intentional that there is no proposal at this stage. It is just a description of the problems. Freedom of movement and patient mobility is not something which is being introduced by the European Commission – I think we discussed that in the past as well – it is something which has been recognised, whether we like it or not – and I hope we like it! – by the European Court of Justice, which has established that the internal market rules apply also to health, even if this is publicly funded.

So this is not a question of a Commission initiative introducing a new concept but how we in the Commission, together with Parliament and the Member States, can make this concept, this reality, work for the benefit of patients without being to the detriment of the national healthcare systems, their viability and their operation.

This is a big challenge for us but I think it is a big opportunity as well, and we can make it work for the benefit of citizens.


  El Presidente. Para cerrar el debate se ha presentado una propuesta de resolución de conformidad con el apartado 5 del artículo 108 del Reglamento.

Se cierra el debate.

La votación tendrá lugar el jueves a las 12.00 horas.

Atnaujinta: 2007 m. gegužės 15 d.Teisinis pranešimas