Full text 
Procedure : 2006/2275(INI)
Document stages in plenary
Document selected : A6-0173/2007

Texts tabled :


Debates :

PV 21/05/2007 - 15
CRE 21/05/2007 - 15

Votes :

PV 23/05/2007 - 5.6
CRE 23/05/2007 - 5.6
Explanations of votes

Texts adopted :


Verbatim report of proceedings
Monday, 21 May 2007 - Strasbourg OJ edition

15. The exclusion of health services from the Services Directive (debate)

  President. – The next item is the report (A6-0173/2007) by Bernadette Vergnaud, on behalf of the Committee on Internal Market and Consumer Protection, on the impact and consequences of the exclusion of health services from the Directive on services in the internal market (2006/2275(INI)).


  Bernadette Vergnaud (PSE), rapporteur. – (FR) Madam President, Commissioner, ladies and gentlemen, health services constitute one of the pillars of the European social model. That is why they have been excluded from the Services Directive and must be dealt with in their own right, as part of a more wide-ranging assessment of the health sector in Europe.

The Commission consultation cannot be reduced to patient mobility alone, but should be an opportunity to define what the role and the added value of the European Union might be when it comes to guaranteeing every citizen not only equal access to health care, but also a high level of health protection, in accordance with the powers of the Member States and with the principle of subsidiarity.

European health policy cannot be limited to the mobility of patients and health professionals and cannot aim solely at the implementation of an internal market in health services, as this would lead to a two-speed system, from which only the most well-off patients would benefit and where health care institutions would seek to attract the wealthiest patients. Furthermore, due to the disparity in professionals' income, medical demography problems will undermine access to health care in the Member States in which service providers do not earn as much, with these people being tempted to settle abroad. Patients must have the right to receive health care in another Member State, in accordance with freedom of movement, but there is no question of promoting medical tourism.

Although health services are subject to the rules of the Treaty, they cannot be considered as ordinary commercial services because they are invested with a mission of general interest. There needs to be a balance between freedom of movement and predominant national objectives connected with the management of hospital capacity, the monitoring of health care expenditure and the financial balance of social security systems. Furthermore, the Member States remain responsible for organising, planning and funding their health care systems.

All European citizens, whatever their income and place of residence, must have equal and affordable access to health care, in accordance with the principles of universality, quality, safety, continuity and solidarity. That is how we will contribute to the social and territorial cohesion of the Union while ensuring the financial sustainability of national health care systems. Patient mobility must not in fact serve as an excuse for the Member States to neglect their own systems.

The Court judgments have, according to how matters have turned out, introduced a number of concepts that are worthy of clarification. This is the case for the distinction between hospital care and non-hospital care, as well as the notion of reasonable waiting time. I regret that the Commission has made only fleeting reference to the mobility of health professionals, when this subject requires in-depth examination. The shortage of staff in European health services will only get worse over time. What is more, we are faced with an ageing population. Is it sensible, then, not to tackle this issue starting today? I do not think so.

The Union must commit itself to providing comprehensive information to patients, so that they can make choices with full knowledge of the facts: who can care for them and according to which procedures? It is from that moment on, when all of these procedure- and criteria-related issues have been resolved, that we will truly have on our territory ‘European patients without borders’. In terms of cooperation, the Union could encourage the implementation of a European network of reference centres, or exchanges of knowledge between the various countries regarding the best treatment methods.

It is regrettable that the consultation should have described social services in a restrictive fashion, because, when it comes to integration, there is a dimension to these services that goes beyond mere assistance and action to help the poorest people. Furthermore, the artificial distinction between health services and social services of general interest ignores the reality of the services that are provided. In many cases, social services and health services are provided in the same way. This is particularly the case where health services with social support are concerned. What about the provision of medical care for old people’s homes and specialised institutes for disabled people?

Contrary to what the Commission consultation was implying, the judgments of the European Court of Justice no more stipulate that Parliament must limit itself merely to codifying the case-law than they prevent it from exercising in full its role as legislator. The decisions of the Court, taken as they are with reference to specific cases, are not enough to define a health policy. Decisions must be taken as part of the democratic decision-making process.

In view of the countless number of infringement proceedings brought by the Directorate-General for the Internal Market in the field of health care and of the unsatisfactory legal situation in which the user-citizens find themselves, we need, for consistency's sake, to lay down a directive on health services that spells out the common values and the principles applicable to health care systems in the Union, and this, so that the citizens regain confidence in Europe in one area of their everyday lives – health care – for their health is their most precious asset. The added value of the Union can be crucial in this sense and can also give impetus to the Lisbon Strategy.


  Markos Kyprianou, Member of the Commission. Madam President, I am very pleased to have the opportunity to discuss this issue again with you. We have discussed it on numerous occasions, including in committee.

We are dealing with a real situation today. On the one hand, there are a series of judgments by the European Court of Justice and the jurisprudence created in this field and, on the other, the decision of the European Parliament, which the Commission has accepted and agreed to, not to include health services in the Services Directive.

As promised, at the time when the debate was taking place and upon the exclusion of health services from the Services Directive, we initiated action in a specific area of healthcare at European level; hence our initiative to begin with a consultation document, to start public consultation and then to continue with a more specific proposal.

The public consultation is finished and we already have the results. We have already had two ministerial discussions on this issue and, with your debate today, we will have a more complete picture of the position not only of the institutions but also of the European citizens and we will then be ready for the next phase, which will be the drafting of the proposal. I can assure you that today’s discussion and of course the report will make a significant contribution as to how we will proceed in this respect. Therefore I should like to thank the rapporteur and congratulate her on a very thorough and comprehensive report and I should also like to thank the other committees for contributing to it.

We are in the middle of this process, which allows us to bring the setting of policies back to the policymakers – those who have the mandate to decide and propose policies will do so in this important area.

As I have said, we have finished the consultation process. We had more than 300 contributions from Member States, regional authorities, organisations representing patients and professionals as well as healthcare providers – even hospitals and individual citizens. Even though there were different views depending on the background of each contribution, there was nevertheless one common approach: there is added value if European action is taken in this respect. The debate goes beyond patient mobility and covers many other areas, such as information for patients, patients’ rights, the movement of professionals, cooperation of healthcare assistants, centres of excellence, exchange of best practice in all areas that could contribute to effective cross-border healthcare for the benefit of patients, the citizens – our foremost concern – without creating any unnecessary burden on the healthcare systems in the Member States.

All these contributions and your report today will be a very important reference point for our next step, which will be a specific proposal.

We recognise that health services have a specificity – they are distinct from other services in the European Union – and therefore the challenge is how to make a choice between the internal market and social values and put in place a framework that can bring both the benefits of freedom of movement on the one hand and respect for health objectives and social values on the other, especially as this was recently confirmed by the health ministers at the informal Council meeting in Aachen.

I believe that Parliament’s report broadly reflects the issues that were identified by many stakeholders and the ministers. This underlines the need to take action at European level.

Concerning the instrument we can use, as I said at the beginning, last year health services were excluded from the scope of the Services Directive at the request of the European Parliament, and the Commission was invited to come up with specific proposals on health services. The Commission agreed to this approach and therefore it does not intend to reopen the discussion regarding possible reinclusion in the Services Directive. On the contrary, we are now in the final stages of preparing a specific proposal directed at those specific issues. It will be a package with various measures, but the first one will comprise, as called for in the report, specific legislative proposals in this area. We will follow this up with various other steps.

However, as I have said, the main objective for all of us is the benefit of European citizens, of European patients, with the principle of subsidiarity always being taken into account.


  Harald Ettl (PSE), draftsman of the opinion of the Committee on Employment and Social Affairs. – (DE) Madam President, Commissioner, all members of the European public attach great importance to high-quality health services, and health becomes even more important in view of the ageing population right across Europe. Health services pursue the same objectives as do other social services of general interest and are founded upon the solidarity principle, fundamental values and equality of access, while universality, equal treatment and solidarity must continue to be ensured.

The Committee on Employment and Social Affairs has once again confirmed that the exclusion of health services from the scope of the services directive was motivated by the desire to identify health services as a higher good for the European Union, and that the adjustment of the voting result from the Committee on the Internal Market and Consumer Protection in the plenary is necessary if a false signal is not to be sent in respect of the ongoing process. These services must be recognised by means of further legislation at European level and must not be made subject to free competition.

What is needed is a legal framework, a proposal, which might, for example, take the form of a sectoral directive for health care services on which the social partners and decision-makers would be consulted, and with a requirement for clear rules on liability for injury sustained by patients during treatment.

Reimbursement of costs must be transparent and comprehensible, and uniform social, labour and quality standards must be complied with when service providers establish themselves; health services are not just services of any sort or kind, and we must handle them carefully, because, in the final analysis, it is your health, too, that they are all about.




  Jules Maaten (ALDE), draftsman of the opinion of the Committee on the Environment, Public Health and Food Safety. (NL) Mr President, on behalf of the Committee on the Environment, Public Health and Food Safety, I, in turn, should like to add my comments to this debate. It is obvious that health services form an integral part of European social infrastructure; if anything specifically typifies Europe and sets it apart out from elsewhere, it is the way in which we make a high level of health care available to all citizens, irrespective of their personal backgrounds.

Our guiding principle in this entire discussion is therefore that, in the final analysis, high-level care must be available to patients and ideally as close to their homes as possible, since that is what most patients appear to need. There are, of course, situations where this is impossible, however; it may not be possible by reason of waiting lists or in the case of rare diseases that can only be dealt with in a European context.

Although health care is first and foremost the responsibility of the Member States, the Committee on the Environment, Public Health and Food Safety is glad that the Commission has taken the initiative in getting the consultation procedure started, in order to see what the best plan of action is for the European Union.


  Charlotte Cederschiöld, on behalf of the PPE-DE Group. (SV) We are not concerned in this case with the Services Directive, even though anyone listening to the debate might think we were. What we are really concerned with is how we are to solve the problems to do with the fact that health care services are not covered by the Services Directive. In particular, we are concerned with how, in spite of that fact, patients and service providers are to be able to retain their cross-border rights. Current rights have their bases in the Treaties and various legal cases and must not be impaired through secondary legislation, at least not without people being informed of what is happening. It is not so much a question of introducing new services or new rights but of standing up for the rule of law and existing rights.

According to the European Court of Justice, advance notification is a normal method of limitation. We in the Group of the European People’s Party (Christian Democrats) and European Democrats do not wish to increase the use of advance notification. We believe that the few cases approved by the Court as legitimate obstacles to the main rule of freedom of movement for people and services are sufficient.

Advanced health care often requires planning, with fixed structures and funding in place. In this area, the Member States probably still need to have some freedom of movement of their own.

As many speakers have already pointed out, there are big differences between the Member States. The Commission should choose suitable instruments for handling the various parts of this large package and focus on solutions that promote movement, freedom and security for the individual European. We must protect people, not national bureaucracy. We have nothing against specialisation within the EU leading to patients obtaining higher-quality care. As citizens of the EU, we have to embrace cross-border solutions. We are entitled to them, both as patients and as service providers. These solutions exist and must be employed, even if health care is not part of the Services Directive. The Commission is responsible for proposing solutions. I would call on the Commission to codify the legal cases, to highlight the Member States’ responsibility for the content of care and not to accept citizens having fewer rights than they do at present. Parliament and the Commission must support each other.


  Evelyne Gebhardt, on behalf of the PSE Group.(DE) Mr President, Commissioner, we in this House acted with deliberation when excluding health services from the services directive, for these are particular services that needed a particular quality, a high standard of health provision, one, moreover, organised in such a way that everyone, irrespective of where they live or of how much is in their wallets, can actually have access to these health services.

That is at the heart of what we have to do, and that is why, as we have said, these are not commercial services, and the services directive must therefore not apply to them. We were, then, all the more astonished when the Liberals and Conservatives in the committee joined in taking the decisions that health services should once more be included within it. That is absolutely false and I must ask you to think this through again and withdraw this decision, because, as Commissioner Kyprianou has rightly said, we now need to come up with a proper answer to the issues around health care services, and do so taking into consideration the whole range of them that needs to be regulated. Such is the task before us, so let us look forward rather than back, with a view to making possible the provision of health care services to a really high standard.

I call on the Conservatives and the Liberals to ensure that paragraph 71 is once more deleted from this resolution, which is in all other respects a very good one.

I would like to congratulate Mrs Vergnaud on her report, for the broad outlines incorporated in it make of it a positive and forward-looking work showing one way in which we can address these issues, and I am very glad that the Commission, in the person of Commissioner Kyprianou, as well as the Ministers on the Council of Ministers have expressed their wholehearted willingness to go down that road, so let us go forward and address these issues in a specifically sectoral directive, thereby completing a good work for the public.


  Toine Manders, on behalf of the ALDE Group. (NL) Mr President, I should like to thank the Commissioner for his introduction and Mrs Vergnaud for her good cooperation.

Since I have heard it said on several occasions that health services are not to fall within the scope of the Services Directive, I wonder what all this is about. The proposal that comprises the current article is the product of compromises that have been concluded, and due account has therefore been given to the condition on which the Group of the European People’s Party (Christian Democrats) and European Democrats, the Socialist Group in the European Parliament and the Group of the Alliance of Liberals and Democrats for Europe all insist, that being that health services should be included in the Services Directive as a lex specialis.

Since, from what I gather, this has caused quite a commotion, I have tabled a replacement amendment which provides for what the Commissioner mentioned a moment ago. After all, the right balance should be struck between the free movement of services, respect for patients’ rights, the freedom of practising a medical profession in Europe and the freedom of establishment.

This is where the new amendment comes in, and I hope that the PSE Group and the PPE-DE Group can accept this, that we can adopt the amendment jointly, and that we will eventually end up with a fresh proposal which provides for equal treatment and solidarity for all Europeans, and I mean all Europeans, and all European patients.

We must avoid a scenario where medical services are simply considered services of general interest, which means that they would be placed outside the scope of the European Treaty, with the effect that each Member State would again set up its own system, that borders would be closed, that there would be no freedom, that patients would not be recognised as having rights and that the rich would jet out to Peking to get the best treatment money can buy instead of seeking treatment in Europe.

If that is what Europe sets out to do, then I think we are at risk of reverting back to the seventeenth century, which may have been a golden age, but does not, I think, represent what Europe is striving to be.

I therefore hope that the amendment that has been tabled by the Liberal Group by way of replacement of Article 71 will meet with wide support, so that a separate directive for health services can be drawn up, and that all compromise amendments can be endorsed, which, in any event, they are by us, as the package is excellent. I hope that we will succeed in what we are setting out to achieve.


  Pierre Jonckheer, on behalf of the Verts/ALE Group. (FR) Mr President, the Group of the Greens/European Free Alliance has given its support to the work of Mrs Vergnaud, whom I should like, moreover, to thank for her receptiveness.

That being said, I must indeed confess that I preferred her first report, which consisted of fewer than 30 paragraphs. I invite the Commissioner and our fellow Members to read the explanatory statement, which has not been amended and which I feel is much clearer than the 72 paragraphs that we have now.

My group has re-tabled a number of amendments, confirming for some the exclusion of health services from the Services Directive and clearly endorsing, for others, the need for specific legislation, while highlighting the fact that a number of regulations already exist, not least Regulation (EC) No 883/2004, on the basis of which mobility and the reimbursement of a number of health services take place.

I believe that, in this debate, we can clearly see that the difficulty in this matter, as in others, is the advantage to be gained not only by the national governments, but also by those operating in the health care systems in each of the countries, on the one hand, in keeping control of the organisation and funding of health care generally, and, on the other hand, in not allowing the Court of Justice judgments alone to provide unwanted guidelines. I am thinking in particular of what is referred to as ‘promoting medical tourism in the European Union'. I believe, and many operators believe, that this is an undesirable development.

On the other hand – and, on this point, too, I would draw your attention not only to our own amendments, but also to the amendments tabled by the Confederal Group of the European United Left/Nordic Green Left – I believe that we must reaffirm very, very clearly the responsibility that each of the Member States has to guarantee access to high-quality health care to its citizens and to all those residing on its territory. I do not think that it is a good thing to have to travel 300 km, 500 km or 2 000 km in order to go, for example, and receive proper dental care, as is the case at present. I do not believe that that is really the best solution.

It is in this spirit that we will therefore reserve our final vote, in view of the votes that will be cast on the various amendments.


  Søren Bo Søndergaard, on behalf of the GUE/NGL Group. (DA) Mr President, when it comes to health, our position is clear. We think that it is a fundamental right for everyone that they be able to enjoy equal opportunities for high-quality local health care. We therefore also wish to state that every single government in every single one of the 27 EU Member States is responsible for ensuring that its citizens receive proper health care. It is also our clear view that those governments that do not wish, or are unable, to guarantee their citizens proper health care do not deserve the latter’s support.

We are therefore also opposed to the report that we are debating in this House today, which would transfer responsibility from the individual governments to market forces. It is certainly no coincidence that the report concludes by calling on the Commission to reintroduce health services into the Services Directive.

We are not opposed to cross-border cooperation in the area of health. We are in favour of close cooperation being established in border regions, partly with a view to ensuring easy access to hospitals in local areas. We are also in favour of cooperation at European level on health care in relation to rare diseases. However, we are opposed to a development whereby patients would be transported all around the EU to wherever would be financially more advantageous for those who pay the costs. We have accepted this method for too long when it comes to pigs. We must not introduce it where human patients are concerned. On behalf of our group, I must therefore call on my fellow Members to vote against the proposal in its present form.


  Jens-Peter Bonde, on behalf of the IND/DEM Group. (DA) Mr President, health is a human right recognised by the United Nations. The right to a high level of health is guaranteed by the Treaty in connection with all EU policies. Instead of removing subsidies for unhealthy products, adherents of the internal market now want to see health turned into a commodity that can be sold freely under market conditions. This would provide a wider range of health services to those who could afford them but a narrower range to those who could not afford to pay the market price. It would provide low-cost services to rich people travelling to poor countries for health check-ups. It would make it correspondingly more difficult for most people in the poor countries and for many poor people in the rich countries to pay for health services. The Services Directive would provide for competition over salaries in the health sector. Foreign companies would be free to establish themselves and offer health services of any type. Danish taxpayers would be forced to pay the same subsidies to all suppliers, irrespective of quality and of the salaries paid. We might as well send our Danish agreement model with its democratically adopted agreements to the museum of labour. People might go to the polls, but we could no longer vote in favour of health care for all. Instead, we should allow the Member States themselves to determine the balance they want to see in the health system between private and public provision and we should respect the Danish model with its tax-funded social and health-care rights for all, as well as our agreement model in the labour market.


  Irena Belohorská (NI). – (SK) In her report the rapporteur deals with several very serious issues currently facing the European Union, including medical services reimbursement policy, the mobility of patients or health professionals and liability for errors.

I would like to emphasise that a patient must not in any way be considered a tourist or healthcare shopper. Patients seek healthcare abroad because certain services are not provided in their home countries or because the waiting period is exceedingly long. The risk of medical service provision becoming the object healthcare tourism is slim. Patients would rather be treated in a familiar environment close to their relatives and where they understand the language. According to statistics, patient mobility accounts for approximately 1% of healthcare services. Given the safeguards of the free movement of persons, however, this percentage will definitely go up in the future. There can be no free movement of persons without access to healthcare services. Therefore, it is our job to ensure such access without complicated negotiations with insurance companies. This solution would also be consistent with the equal rights of citizens across the entire area of the European Union.

I have not found any reference in the report to disparities between Member States concerning an individual’s chances of survival. Why do Slovak women suffering from breast cancer have a 30% smaller chance of recovery than Swedish women? Why do Polish patients suffering from rectal cancer have a 30% worse outlook for survival than French patients?

For many people, patient mobility (even though a mere 1%) seems to be a key problem. However, no one is interested in the fact that a great number of physicians and nurses have left the twelve new Member States. Why are we so preoccupied with the problem of patient mobility and yet disregard the mobility of physicians?

I urge the Commission to come up with a new draft strategy proposing a solution for this issue in the future by promoting eHealth, the levelling off of disparities between the Member States and the use of structural funds for healthcare purposes.


  Marianne Thyssen (PPE-DE). – (NL) Mr President, Commissioner, ladies and gentlemen, the title of the own-initiative report that we are debating mentions the good reason for its being drafted: the exclusion of health services from the scope of the Services Directive. I should like to remind you of the fact that this exclusion has been brought about as a result of the decision taken by a broad majority in this House, a decision in which both the Commission and the Council gave us their unanimous backing.

It was, as I see it, a fair decision, firstly because health services cannot be treated in the same way as traditional commercial services, secondly because a patient is not a consumer and thirdly, because the Member States have key authority and responsibility when it comes to organising and funding health care within their territory. I am therefore relying on us being able to lay down a resolution on Wednesday that is consistent in this area.

Meanwhile, health services remain, of course, services within the meaning of the Treaty and as such, the rights and freedoms of the Treaty apply. We refuse, as we did in the case of the Services Directive at the time, to leave everything to the Court of Justice, and once again, we are forced to reconcile various objectives with each other. The internal market should work as efficiently as possible while room should also be left for health policy that is justified in every way. What we need to heed in this is a sense of balance and legal certainty.

A codification of existing case law on the rights and duties of both mobile patients and mobile service providers is certainly called for, but it is not enough. What remains a challenge is the creation of added value for people and in the area of the quality of care and of guaranteeing leeway for the Member States, thus enabling them, as before, to be responsible in making the choices that they have to make.

We have not yet reached consensus on what exactly should be covered in European legislation using what instruments, but I am persuaded that this report, the inquiry which the Commissioner has organised and also the earlier resolution on patient mobility are valid contributions to further develop policy in this area, and we are looking forward to the Commissioner’s initiatives in this respect.


  Robert Goebbels (PSE). – (FR) Mr President, Commissioner, ladies and gentlemen, the initial report by my esteemed colleague, Mrs Vergnaud, should, in theory, gain the support of all the Members.

The objective of enabling everyone – everyone in Europe – to receive adequate health care when they move around Europe, for professional and private reasons, simply falls within the realm of freedom of movement.

However, patients’ right to mobility can be guaranteed only if the EU Member States retain the power to regulate these health services, so that they can control the funding of them, because, while health has no price, it has a cost, and a growing cost at that. This cost is becoming more and more substantial, and there is the risk that it will become impossible to manage the funding of social protection and health services for all in all of our Member States.

Certain political forces within this Parliament have a simplistic response to this concern, which is shared by virtually all of the ministers for health: leave the market alone and entrust the funding of social security to private insurance companies.

I suspect also that Commissioner Kyprianou shares these somewhat ultraliberal views. He said to the Figaro that competition between European health services is inevitable and, to the Financial Times, that people can shop around.

The Socialist Group in the European Parliament does not share that view. It is in favour of the right to health care for all throughout Europe, but is against a market that will enable the wealthiest people to have the best possible treatment, while the poorest and least mobile people will have the right only to a minimum level of treatment.

Those who believe that the market, and the market alone, could guarantee high-quality health care for all should reflect on the situation in the United States. In that great country, the cost of health care is the highest in the world, that is, some 15% of GDP, or practically double the European average. However, that very expensive system is excluding a growing number of US citizens: in 2006, 46.6 million Americans had no medical insurance. That is certainly not an example that Europe should follow.


  Antonyia Parvanova (ALDE). – Mr President, I too would like to thank Mrs Vergnaud for the wonderful cooperation we enjoyed in the preparation of this report. This Parliament recently adopted a resolution on cross-border healthcare and today we are discussing another one. Why? Because, as access to healthcare and health services becomes an issue for Europe, the exclusion of health services from the Services Directive set us an urgent task to ensure that in future legislation people will have access to healthcare regardless of state borders.

The Court of Justice decision clearly recognised the application of internal market principles and freedoms when patients seek treatment abroad. We should secure common levels of safety and quality of health services and implementation in practice of patients’ and citizens’ rights across the EU. Patients’ rights should be part of future Community health legislation. We should recognise the two dimensions of cross-border mobility and ensure that unjustified delays for patients and healthcare professionals will be removed. Patients should have access to innovative treatments and technologies for their health. We should govern the process and create an empowering environment for it.

Legal certainty is needed in medical practice, as is right of establishment to guarantee high-level safety and quality standards. Current EU legislation does not cover the regulatory gap. The Commission should introduce an initiative that observes the above-mentioned principles.


  Kartika Tamara Liotard (GUE/NGL). – (NL) Mr President, two years ago, when we were discussing the Services Directive and I was this House’s rapporteur for health care, I recommended that health services be excluded from the Services Directive, which advice the House proceeded to follow. It saddens me deeply that, now that there is a proposal to undo this, Parliament, if it approves this reversal, will lose every ounce of credibility over it.

I am not just referring to Mr Manders's repugnant amendment to bring health services back within the scope of the Services Directive – he seems, however, to be eating his words to some extent, but the essence of what he said remains the same – but also the whole idea of an EU directive for health services strikes me as excessive interference.

Needless to say, a proposal must be drafted to guarantee the right of patients to get care across the border in a decent manner, but this should not lead to Member States neglecting their responsibilities for providing good quality care and the right amount of it. Patients prefer to be cared for well, close to home, and in their families. Legal tug-of-war should certainly not be used as an excuse to liberalise EU health services.

Health services occupy a specific place in society. Accessibility and quality, rather than making a profit, should always remain the foremost priorities. Care is not a market, and Europe should not try to turn it into one. Article 152 of the Treaty stipulates that health care is a matter for the Member States and this is how, as I see it, in the interests of the patient and employees in health care, it should certainly stay.


  Jeffrey Titford (IND/DEM). – Mr President, this report is seriously advocating that cross-border healthcare should become a reality under the Services Directive. It states that ‘Member States should treat residents of another Member State on an equal basis with regard to access to health services, regardless of whether they are private or public patients’. It also states that there should be ‘a codification of existing case law on the reimbursement of cross-border healthcare’.

Let us be clear exactly what these two statements mean as far as Britain is concerned. The first is saying that a visitor or migrant from another EU country, who has not paid a bean towards the cost of the National Health Service, should be entitled to the same access to healthcare as a British resident who has been paying tax and national insurance all his or her working life, and means a delay in their treatment. The second statement opens the door for the EU to override national governments and lay down the law on how cross-border healthcare is reimbursed, leading inevitably to how healthcare as a whole is funded and managed. A single healthcare system run by the EU is a nightmare too horrible to contemplate; it should never be unleashed on an unsuspecting world.


  Malcolm Harbour (PPE-DE). – Mr President, health services will remain the province of Member States and healthcare organisations will be the responsibility of Member State governments. But that does not stop our citizens from travelling, from falling ill while they are travelling, from moving permanently to other countries and wanting access to healthcare – perhaps something that Mr Titford might care to reflect on in a quieter moment.

I want to thank Mrs Vergnaud for this report. It is an extremely comprehensive one. It has many valuable contributions to the work that you, Commissioner, set out and it is extremely timely. It is quite clear that health services are not going to be reintroduced into the Services Directive. We will certainly support the compromise proposal that Mr Manders will table tomorrow making that clear.

That should not distract us from looking at some of the really important issues that are picked up in this proposal, because more and more people are going to be challenging the boundaries of the system. One of the landmark Court of Justice judgments was because of a British patient who travelled to another country to have a hip replacement operation on the grounds that her own health service – sadly in my own country – could not provide that treatment within anything like an acceptable time. The Court found in her favour and that is something that the Commissioner will reflect on. I do not object to the basis of that judgment because it seems to me that this is a right that people should have across the European Union.

But there are going to be very difficult issues that we are just starting to face. The innovatory treatments that one of the previous speakers mentioned, particularly in the areas of cancer, are already presenting really difficult issues to public health services. Expensive, life-prolonging tailored treatments: what happens if they are available in another country but not your own and you travel to that country and ask for that sort of treatment to prolong your life?

This is an important report. It is an issue that we are going to be increasingly confronted with. I commend it to you and I hope the Commissioner will come up with an imaginative response.


  Harlem Désir (PSE). – (FR) Mr President, I should like to begin by thanking our rapporteur, Mrs Vergnaud, who unfortunately had her work cut out with the Committee on the Internal Market and Consumer Protection because, as Commissioner Kyprianou pointed out to us, we have, on the one hand, case-law, that is to say, in fact, the Treaties as interpreted by the Court of Justice, and, on the other hand, the position adopted by the European Parliament during the vote on the Services Directive, a position that clearly stated that a choice needed to be made between what falls under the internal market and what, for the sake of defending the social values of the Union, must fall under other mechanisms.

I believe, in fact, that the Committee on the Internal Market and Consumer Protection – not just Mr Manders, unfortunately, since, in order to have a majority, the members of the Group of the European People’s Party (Christian Democrats) and European Democrats and of the Group of the Alliance of Liberals and Democrats for Europe had to support it – has done something very regrettable in seeking to re-introduce health services into the framework of the directive on services in the internal market: in none of our countries, in fact, are commercial services and construction, on the one hand, and hospital services and patient services, on the other, included in the same legislation. There are, in fact, different rationales.

It is true, firstly, that we need to act in accordance with subsidiarity, with the mechanisms for funding our social systems and with the authorisation mechanisms of health care institutions, but we must also take account of the European area and of movement in that area, and thus promote access for all to health services. This must, however, fall within the realm of specific mechanisms. That is why, just as we need them for social services of general interest and, moreover, just as we need them for all the other services of general economic interest, I believe that we need specific directives, alongside the directive governing commercial services in the internal market.

I hope not only that the compromise will make it possible to clarify the fact that health services are not in the directive on services in the internal market, but also that we will actually demand a specific directive on health services.


  Eva-Britt Svensson (GUE/NGL). – (SV) It is not long since the two large political groups reached a compromise on the Services Directive, and some people described it as a great success that health care and medical services had been exempted. There is now nonetheless an attempt to introduce this deregulation through the back door, in which case medical and health care would cease to be human rights and become commodities in a market.

According to the Treaties, medical and health care are the exclusive responsibility of the Member States, and legislation at EU level is neither required nor desirable. Cooperation is good, but legislation is not, in this instance.

I hope that those who thought that the removal of medical and health care services from the Services Directive was to be applauded will make sure that they consolidate that success by supporting the amendments by the Confederal Group of the European United Left/Nordic Green Left when we vote.


  Othmar Karas (PPE-DE).(DE) Mr President, ladies and gentlemen, I hope that all those who, in the committee, voted in favour of paragraph 71, now at least realise what a disservice they have done to the debate, for we are now talking less about the substantive issue than about the methodology involved.

Our removal of health and social care services from the scope of the services directive was quite deliberate. Why did we do it? For the fact is that this is not about the free market versus the national interest, but about our understanding of the vulnerability of the health sector and social services, and about our willingness to regulate these sectors in very specific ways rather than evaluating them solely in terms of the workings of the market.

What we have to do is to define just which health services we are actually talking about, to decide just which services are covered by the subsidiarity principle, for such services cannot, indeed, by reason of their character, be seen as ordinary services subject to the operation of the market, and the public need to be protected.

I shall be very frank in saying that I am very sad that the vote in the Committee on the Internal Market and Consumer Protection on the Liberals’ amendment made things less than certain; the overwhelming majority in this House rejects paragraph 71, and that includes us, for it amounts to a backward step, and we want to make an active contribution to the process of consultation on the regulation which the services directive set in motion.

Let us not constantly confuse the mobility of patients with the way we handle the freedom to provide services. Patient mobility is not a matter of dispute. The issue of how to regulate the freedom of entrepreneurs to provide services demands a nuanced regulation and careful handling, and the Member States must not be discharged from their responsibilities in that respect, for it is they – and not those who make Europe’s laws – who have to ensure the highest quality standards.


  Edit Herczog (PSE). (HU) I welcome the fact that when numerous European Union Member States are working on reforming their health care systems, the European Parliament should also examine the question in a separate report, and I congratulate my fellow Member, Mrs Vergnaud, on her work.

Health care is an area in which tension between social and economic opportunities and obligations increasingly prevails. The technological and digital revolution of the contemporary world tantalises us with ever more promising solutions in the field of prevention, treatment and cure, but the high costs of progress are beyond the reach of many. We can say that the task of a social Europe, a Europe of solidarity, is to ensure that every citizen of the European Union can access advanced medical services, regardless of his or her nationality, income or national boundaries.

Certainly public health is not an economic, industrial or commercial service. Yet the services that support and gravitate around health care are almost exclusively profit-oriented sectors, and indeed they need their profits to sustain further research and development and innovation.

Europe, and we European politicians, must therefore also find a solution to ensuring that the markets in prevention, nutrition, leisure, diagnostic tools or medicines and medical instruments do not rely solely on the already scarce public health resources in order to be able to grow.

Although we are only now looking for solutions to the above challenges, what is certain is that a precondition of every solution is that the burden be borne jointly, as something that is the responsibility of all 485 million inhabitants. It is unacceptable, for instance, that in Hungary there are 1 million people, and not the poorest among them, who make use of universal health care without paying a single penny into common funds. Social and economic solidarity demands that employees and employers contribute to the realisation of legal security and equality before the law.


  Dimitrios Papadimoulis (GUE/NGL).(EL) Mr President, the provision of health care is a public service and cannot be left to the unaccountability of the free market. The appropriate framework for addressing the mobility of patients exists in Regulations (EC) Nos 1408 and 883/2004. All problems can be regulated within this framework, not by overturning it.

Addressing health services à la Bolkenstein will result in a lower standard of health services, in a reduction in public services for the benefit of private services and, of course, in less health protection for the socially weaker.

The effort to integrate health services into the Bolkenstein Directive ‘through the back door’ with the famous Manders Directive and/or with the amended directive waiting in the wings must be rejected categorically.

For the European Parliament, which voted differently on this issue a few months ago, this stand is a serious question of credibility and consistency. I trust that we will not change our tune again this time.


  Zuzana Roithová (PPE-DE).(CS) Ladies and gentlemen, the Member States must respect European Court of Justice rulings and the Commission must integrate them into social security regulations. I am talking about the right to the reimbursement of healthcare costs abroad. When patients receive first aid they do not have to seek approval first from their insurance company. The Commission and the Member States must reach agreement on what is considered non-urgent care for which the patient has to request this prior consent. Last year Parliament succumbed to false arguments and, under pressure from the left, the unions and some governments, removed healthcare from the services directive. Consequently, this right has yet to be implemented in law, since Regulation 1408 from 1971 has not been updated.

The idea that mobility would lead to a deterioration in care is nonsense. I therefore call for greater trust in foreign healthcare, and for the associated right of patients to information on the quality of healthcare facilities. We call on the Commission and the Member States to coordinate healthcare quality control systems, without the Union impinging on the powers of the state. The key programmes are Patient Safety and national or international accreditation for hospitals and ambulance services. If patients are informed about which foreign hospitals are voluntarily abiding by international or national standards, they will feel more confident of being well looked after even if they perhaps do not speak the language. This is the most important factor when it comes to trust in European healthcare and to rebutting expedient arguments against patient mobility.

I know that my proposal to remove obstacles to the provision of non-State – that is to say, private – services abroad has become a political issue. It is my fervent wish that doctors and nurses may overcome the obstacles put in their way by politicians, who play down the public’s right to a wider selection of health services and are frightened of free choice.


  Barbara Weiler (PSE).(DE) Mr President, ladies and gentlemen, I would just like to start by giving the Commission credit for consulting this House and all the stakeholders at this early stage concerning the new directive, something of which I am sure one could not always be certain. This makes me confident that the new directive is being planned carefully and will incorporate not only the relevant assessments of impact on society, lawmaking, and subsidiarity, but also European citizens’ rights.

Rules on health care across borders have become necessary, and many members of the public expect them to be in place – I am referring to workers in our border regions, to migratory workers, to pensioners in south-eastern Europe and Greece, and, indeed, to Europe’s long-distance drivers, about whom I have just been reminded – and not only to all these, but also to all the other workers who were formerly unable to benefit from these things, which were – as has been said a couple of times – reserved to private patients. It is for that reason that I find it all the more absurd that the Confederal Group of the European United Left/Nordic Green Left in this House want to further entrench the privileges of those with private health insurance.

If the opening up of the national systems is done with caution and care, it will be something from which we can all benefit. Constructive competition among service providers, competition between the best methods, the most useful research and the most successful strategies in the health sector – all these things can be useful, subject, of course, to the criteria to which I have already referred and which do not apply in the internal market, namely quality, safety, solidarity and sustainability.

I am sure that this House will not fail under any circumstances in allowing those criteria to prevail.


  Milan Gaľa (PPE-DE). – (SK) I would like to thank Mrs Vergnaud and the shadow rapporteurs for their work.

First of all, I would like to speak about the different types of mobility possible in healthcare. For example, the cross-border provision of medical services, meaning that a service is provided from one country to another without patients and health professionals leaving their home territory. Such services include telemedicine, remote diagnosis, remote drug prescription and others. Secondly, there is patient mobility in the conventional sense, which we are mostly talking about. More specifically, it is the use of services abroad, when a patient goes to where the provider is established in order to be treated. Thirdly, qualified persons may be temporarily present in another Member State, which is known as the mobility of health professionals with the aim of providing services. The fourth possibility is to provide such services permanently, by establishing healthcare facilities in another Member State, as my colleague, Mr Karas, indicated before me.

For all of these types of mobility to be gradually legislated and subsequently implemented, we must first formulate and answer several basic questions. These are as follows: Are there common values and principles for healthcare which all EU citizens can rely on? How can we ensure a reasonable financial compensation mechanism? How can patients and experts identify and compare healthcare providers? To what extent are Member States flexible in eliminating unjustified obstacles to free movement? How can we ensure long-term care and social services? There are many more such questions.

The Commission, as well as the Council and Parliament, must jointly find answers to these questions through legislation dealing with the effects and consequences of healthcare services being excluded from the directive on services in the internal market.


  Maria Matsouka (PSE).(EL) Mr President, health is not and cannot be approached as a commodity which, even worse, must be subject to market conditions and competition.

Health has a public utility mission and that is why it must meet a series of criteria such as quality, accessibility, universality and solidarity.

We must put an immediate stop to efforts to extend the market philosophy to the health service sector on the pretext of modernising it, which the Court of Justice has facilitated in its own way and which the spokesmen of economic liberalism are now bringing back on stage.

Unfortunately, this has already happened with some social services. Let us not allow it to be repeated here.

There is no point in bringing health services back within the scope of the Services Directive. This approach was rejected by the European Parliament last November.

The European Commission must have the courage, it must use its right to take legislative initiatives and propose a sectoral directive on health services. It must also have the courage to propose a framework directive regulating social services of general interest.

You, my honourable friends of the right-wing majority, have contributed once again to the lack of credibility of the Union, by unexpectedly reintroducing the question of bringing health services under the Services Directive, known as the Bolkenstein Directive.

Act in accordance with your responsibilities and do not play with the lives of European citizens. Prove with your vote that health is not a commodity.



  Markos Kyprianou, Member of the Commission. (FR) Mr President, I shall begin in French for the purposes of saying something to Mr Goebbels. I have been described in many different ways during my political life, but this is the first time that I have been called an ultra-liberal.

That is why I should like to explain myself, because I believe that the statement that I made to the Figaro and also to the Financial Times has not been understood correctly. So that I can ensure that I am understood correctly, I shall continue in English.

What I was saying to the newspapers was that the existing situation was not my policy. What I was describing – and I would like to come back to this – was the reality after the European Court of Justice judgments, which stated that internal market rules apply to healthcare even if it is publicly funded.

Probably it is not Parliament’s policy, but it is a reality with which we have to work. It is inevitable that, if people can travel to seek treatment abroad, there may be some competition; people should have the choice. So the challenge for us is how we can make this right, recognised by the European Court of Justice, work primarily for the benefit of European citizens but not so as to undermine and destroy Member States’ healthcare systems.

A lot has been said about the subsidiarity in Article 152 and I would like to remind you of what the Court said on that. The Court said that, even though Member States have the right to organise and deliver health services and medical care, this does not exclude the possibility that Member States may be required under other Treaty provisions to make adjustments to their national health systems. Hence the application of internal market rules.

So this is the first legal reality we have to work with, but of course we also have a factual reality. Unfortunately there are inequalities in European healthcare systems: Member States cannot offer the same level of healthcare to their citizens. People who seek treatment travel abroad and, if they are refused this right, they go to the Court of Justice. I think you will agree with me that we cannot have every citizen going to Luxembourg and seeking a judgment from the European Court of Justice to decide whether he or she can have an operation.

That is why we are faced with the challenge of how can we make these principles established by the Court work both for citizens and Member States. I must emphasise that our main target is to deal with the inequalities that exist in the European Union. We have policies and strategies, which we will be able to discuss later this year, on how to achieve this.

It is also very important that we recognise what has been said already, i.e. that citizens would rather have treatment at home, near where they live, and this is the main priority for all of us. But, until we deal with inequalities, people will need to seek treatment abroad. Also, as we have already said, it makes more sense in border regions to cross the border than to take a long journey to your country’s capital. There are also scientific reasons: sometimes specialised treatments may be better provided in another Member State.

The existing legislation does not cover these issues because it is not just a question of patient mobility. We are also working on safety, quality, patients’ rights and the patient’s right to information. All these require legislation that is more thorough than the existing legislation. Furthermore, the principles in the existing legislation are different from those described by the Court, so we also have to deal with this.

The challenge is how to make all this work. I believe that we are now dealing with one of the most important initiatives in this area. Patient mobility should complement, not replace, the provision of healthcare at home. This is the main objective, but all citizens should have the same opportunities, irrespective of their income or education or language skills. They have to be able to take advantage of this right in a way that will be decided by the policymakers, but it must be decided on the basis of equality for all European citizens.

Medical tourism is a totally different issue. We are not dealing with that, we are not touching on that, we are not encouraging that. This is something that is dealt with by the private sector, private citizens, and private funds. It is not something that we will be working on. Again, it is a reality: people travel because they want to combine holidays with medical treatment, but that is not something we are working on at this time.

It is important to deal with the issue of overall cross-border healthcare as soon as possible – now, proactively – before it becomes too big to handle. It is not just the issue of paying for health assistance, but also the availability of health assistance which may be overburdened by incoming patients. That is another issue we will take into account.

We will combine all the interests of the patients. In view of the realities that we face and in spite of different approaches and different ideologies on the details, it is therefore very important that we work together to achieve what is best for the European citizens. I intend to do that and I hope the European Parliament will work with us to this end.


  Robert Goebbels (PSE). – (FR) Mr President, I should like to acknowledge formally to Commissioner Kyprianou that he is not an ultra-liberal and I have listened very carefully to him explain his general outlines.

That being said, Commissioner, what really shocked me in the Commission communication was the following sentence, which I shall quote: ‘Any Community action must respect the principles already laid down by the Court of Justice in this area'. True, we must comply with the case-law, but, in all of our countries, the legislators are there to, if necessary, change the legal texts if the courts venture into dangerous territory. I believe that the judgments of the Court of Justice are often too liberal. It is up to us, as colegislators, and to the Commission, to get things back on an even keel, if necessary.




  Markos Kyprianou, Member of the Commission. Madam President, I shall be very brief because I do not disagree, but it all depends on the context. I shall not go into the legal argument now, but we will take everything into account. I have said from the beginning, and I do not hesitate to say this publicly, that I believe policy decisions should be taken by the policymakers, not by the courts. We will have the opportunity to discuss a specific proposal, but always bear in mind the parts of the Court’s judgments that interpret the Treaty. When it is the Treaty, which is the ultimate legal instrument in the European Union, legislation has to comply with that. When it is not the Treaty, we have flexibility. However, as I have said, we have legal services to advise us on that. Let us agree on the policies first and then we will find a legal way of doing it.


  President. – The debate is closed.

The vote will take place on Wednesday, 23 May.

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