The
Committee consisted of the following
Members:
Chairman:
Dr.
William
McCrea
Betts,
Mr. Clive
(Sheffield, Attercliffe)
(Lab)
Cunningham,
Tony
(Workington)
(Lab)
Gidley,
Sandra
(Romsey)
(LD)
Kennedy,
Jane
(Liverpool, Wavertree)
(Lab)
Kirkbride,
Miss Julie
(Bromsgrove)
(Con)
Moffat,
Anne
(East Lothian)
(Lab)
O'Brien,
Mr. Stephen
(Eddisbury)
(Con)
Penrose,
John
(Weston-super-Mare)
(Con)
Pugh,
Dr. John
(Southport)
(LD)
Rosindell,
Andrew
(Romford)
(Con)
Sheridan,
Jim
(Paisley and Renfrewshire, North)
(Lab)
Watson,
Mr. Tom
(West Bromwich, East)
(Lab)
Winterton,
Ms Rosie
(Minister of State, Department of
Health)
Mark
Etherton, Committee
Clerk
attended the
Committee
The
following also attended, pursuant to Standing Order No.
119(5):
Dunwoody,
Mrs. Gwyneth
(Crewe and Nantwich)
(Lab)
European
Standing
Committee
Tuesday 16
January
2007
[Dr.
William McCrea
in the
Chair]
EC Action on Health Services
4.30
pm
The
Minister of State, Department of Health (Ms Rosie
Winterton):
It is a pleasure to serve under your
chairmanship, Dr. McCrea. I welcome the opportunity that this debate
provides for right hon. and hon. Members to consider some of the issues
concerning the European Commissions communication on health
services.
Hon. Members
may know, or will have gathered, that the Commission intends to bring
forward legislative proposals on health at some point in 2007 following
consultation. The European Scrutiny Committee expressed its interest in
the matter on a number of occasions and I offered to speak to the
Committee about the latest developments, but it referred the matter to
this Standing Committee for debate because, while it welcomed my offer
to give oral evidence, it considered that the questions posed by the
Commission were
of such
importance and wide interest.
I hope that it will help hon. Members if
I explain some of the background to the Commissions
proposals.
The
communication that we are debating today notes some of the principles
developed by the European Court of Justice on the rights of patients to
go to another EU member state specifically to seek medical treatment at
the expense of their own health system. Those principles derive from
the treaty articles on the free movement of services, which set out the
rights of individuals to access services and for providers to provide
services throughout the European Union. However, recent European Court
judgments have created some legal uncertainty in health matters, which
is unhelpful to member states. The communication also looks broadly at
areas where non-regulatory co-operationfor example, in the
sharing of best practice between doctors in different EU
countriescan be of value to member state Governments
work. It asks what form such co-operation might take and how it can
most effectively be
facilitated.
Last
year, the ECJ delivered its verdict in the case of Mrs.
Watts, who had gone to France to have a hip replacement rather than
wait to have it done on the NHS. She is now claiming the cost of the
operation from the NHS. Without deciding whether she is entitled to
have her costs refundedthat will be decided in the High Court
in Englandthe ECJ judgment confirmed that the legal principles
of patient mobility developed in previous cases brought before the ECJ
apply to the NHS as well as to health care systems based on a system of
social insurance.
Those principles give NHS
patients the right in certain limited circumstances to go abroad
specifically to seek medical treatment at the expense of the NHS.
That should obviously be distinguished from the arrangements that have
existed for many years whereby UK citizens can receive medical
treatment that becomes necessary while travelling in the EU for work or
on holiday, or while living in another EU member
state.
During the past
year, the services directive passed through the European Council and
the European Parliament. In the course of discussion, health care was
excluded from the scope of the directive. That was a key negotiating
point because we thought it was inappropriate to treat health care in
the same way as any other service industry. We and member states
throughout the EU, and the European Parliament felt that it should be
considered as a sector with its own specific features and
importance.
However,
the exclusion of health care from the scope of the services directive
does not exclude it from the application of the provisions of the
European treaty and the law derived from it. The current legal
situation, as defined by ECJ case law, is unhelpful and contains many
areas of ambiguity. For example, it is not clear whether member states
can require a patient seeking non-hospital treatment in another member
state to seek authorisation from their local health care fundin
the UK, that would be the local primary care trustbefore going
for treatment. There is also a lack of clarity about who should take
overall responsibility for the safety and well-being of patients who
cross borders to receive health care. That is clearly unhelpful and
unsatisfactory for patients. For example, who should take
responsibility for the well-being of a patient who goes abroad to seek
treatment of their own accord, but who suffers medical complications
from clinical negligence?
The main driver of the law so
far has been the cases in the European Court of Justice. We feel that
it is inappropriate for the law to develop without appropriate
political input, and that is a view shared by other member states.
Should member states and the EU institutions fail to take action in
that area, the law will continue to develop through individual cases
that are brought before the European Court of Justice, rather than
through due political process.
As a result, last year the
European Council of Health Ministers issued a statement of values and
common principles, a copy of which has been sent to members of the
Committee. That was an important stake in the ground from the member
states, and has helped to set the tone for the discussion that has
followed. Briefly, the statement emphasised that member states have the
responsibility for managing their own health systems, in the manner of
their choosing, and that any proposals at EU level must respect that
fundamental point.
The Commissions
communication is a logical development from the events noted above. It
sets out the areas for discussion and debate among the member states
and with wider groups, such as the health professions, the European
Parliament and patient groups. The consultation on the document closes
at the end of this month. The Commission will then publish a formal
response on the consultation, probably within two or three months. We
expect legislative proposals to follow some time in 2007. Any proposal
will follow the co-decision procedure, which means that it will have to
pass through and be agreed by both the Council of Ministers and the
European Parliament. Any proposal will also be debated initially in the
Council by Health
Ministers.
In the
consultation and the discussions that will follow, we shall work to
protect the UKs interests. We shall argue that the following
principles be reflected in any proposals. Any legislative proposal must
be proportionate, and must not go beyond what is needed to resolve the
specific problems that we face. Any proposal must also provide for a
sustainable way of managing patient mobility. Member state referral
processes must be respected; so, where a referral from a GP is needed
to access a service in the UK, patients should need a similar referral,
from a British GP, to access that service in another EU member
state.
Determining
what treatment is offered to patients is a matter for member states to
decide. Member states must be able to restrict the level of payment for
treatment abroad to the cost of that treatment, if it was delivered in
the UK. It must be the standards, governance and systems of redress of
the member state where the treatment is carried out that apply. Member
states can prioritise treating their own citizens above citizens of
other member states who travel to them specifically to receive medical
treatment. That would permit member states to manage patient mobility
in a sensible and sustainable
manner.
I hope that
right hon. and hon. Members will agree that the motion sets out the key
issues raised in the communication. It would send a good message from
Parliament if we were to agree that this is how we would like any
legislation to develop. I hope that right hon. and hon. Members will
support the Government motion, and that we will work hard to engage the
dossier proactively and to influence its development as much as
possible.
The
Chairman:
For the guidance of the Committee, we now have
until 5.30 pm for questions to the Minister. I have been given guidance
that Members should be brief in their questions and should ask them one
at a time. It is likely that there will be ample time for several
questions from different Members. We will see how we get on and whether
we need to extend the time to make it a profitable
exchange.
Mr.
Stephen O'Brien (Eddisbury) (Con): I am glad, Dr. McCrea,
to have my first opportunity to serve under your chairmanship.
Recognising the style of todays European scrutiny debate, I
note the Ministers opening statement and I am grateful for the
opportunity to question her. I have not noticed this room being used
for Standing Committees before, and I congratulate the officials on
being able to squeeze into the
corner.
It is worth
putting on record at the outset that the Conservative party is
concerned about the motions title. It would be relevant if the
dossier was being debated on the Floor of the House under domestic
legislation, but the motion is entitled EC Action on Health
Services when in fact it concerns a consultation. It is
important to recognise that we are dealing with a consultation. If the
dossier had to do with action to be taken by the European Commission, I
dare say that our depth of worry about some of the things that it
contains and envisages would be that much more
serious.
As a
preliminary to my first question, it is fair as the official
Oppositions spokesman to say that in the light of the ECJ
ruling the Government both have an obligation and are trying to fix a
problem. Inevitably, though, in trying to fix a problem, we are forced
to do something. Doing nothing is not an option. Therefore, in having
to do something, we have a legislative and political event. It has now
been proposed by the Government, obviously seeking the Houses
support, and we need to recognise that we must take this opportunity,
given the technicality, depth and complexity implied, to examine all
the ramifications and implications. It is simply not good enough to say
at a later stage that we ducked our opportunity to understand what the
ECJ ruling and European Commissions proposals were bringing
into our domestic field of social and legislative
behaviour.
As
an introduction, Dr. McCrea, and to ensure that I abide by your ruling
that we should keep questions in a sensible formatmine fall
under certain headingsI thought that Members might find it
helpful if I outlined my main concerns, so that the groups of questions
will be more obvious as they come and Members can decide whether to row
in behind. The first concern that the consultation gives rise to is the
spectre of an EU health service. The second is the threat to member
state autonomy, particularly in finance and ethics. The third is the
threat to UK specialisms and expertise, particularly in biotech. The
fourth is the impact of last summers ECJ ruling and the extent
and power of any European e-health area, to coin a phrase. The fifth is
what responsibilities the UK might accrue to member states with less
developed health care. The sixth area of questioning will examine the
Department of Healths track record in lobbying European
institutions for a successful
outcome.
The
first question is whether we might have to consider the possibility or
ramifications of a pan-European health service. Is the consultation
moving toward that, and does the Minister thus envisage an EU-level
regulator either of the health care market, along the lines of the
Office of Fair Trading, or of the care itself, along the lines of the
Healthcare Commission and the Commission for Social Care Inspection? As
a corollary, how will patient safety and health care quality be
monitored and protected? It is important for the Minister to say what
she makes of the proposals to gather an evidence base at European level
and in respect of a European-level
observatory.
Ms
Winterton:
Legislation is necessary as a result of
European court judgments where there is ambiguity over a number of
issues. In respect of the idea of a European health service, we want
first to clarify the ability of member states to run their own health
care systems, taking into account that issues such as patient mobility
have already arisen through case law because of some of the provisions
of the treaty. We want legislation to clear that up.
I shall set out the principles
on which we base our response. When framing or influencing legislation
we try to make it absolutely clear that we want to retain the right of
member states to run their own health services in the way that they
wish. However, that does
not mean that we cannot consider areas of co-operation; during our
presidency we considered co-operation on patient safety, an issue in
which my right hon. Friend the Member for Liverpool, Wavertree (Jane
Kennedy) was involved. We considered the fact that people may travel
for different health care provision and looked at how we could ensure
that there were certain safety standards that people could expect. That
is one of the areas we are trying to develop.
On some issues it is right that
there should be European co-operation. For example, we have been
considering co-operation on the treatment of a very rare disease in
centres that could also conduct research into such conditions. However,
European co-operation in that area might have to be limited to the
extent that it would not be possible. My officials will remind me of
the condition we were looking
at.
Mrs.
Gwyneth Dunwoody (Crewe and Nantwich) (Lab): It was
rare.
Ms
Winterton:
That is why I cannot remember it. The condition
was rare and it was not possible to provide sufficient back-up for an
individual member state to be able to consider it. We should not see
what is being proposed as threatening; we are trying to clear up
ambiguity that has arisen as a result of European court
decisions.
Mrs.
Dunwoody:
I am grateful to you for allowing me to exercise
my right to ask questions, Dr. McCrea. May I ask the Minister first if
the United Kingdom accepts that only an insurance-based scheme will be
continued in this country and that it will alter the implications in
respect of foreigners being able to use certain parts of the health
service? It seems to be clear from the consultation document that in
future health-related data will be transferred between different health
systems. What is the Governments attitude to that proposal? Do
considerations of confidentiality concern them? What do the Government
estimate will be the cost of British nationals electing to go abroad
without referral from a general practitioner for self-selected
operations, which cannot be clinically controlled by British
consultation? What will be the result of British nationals obtaining
surgical assistance in other EU countries and requiring subsequent
work? Who will be responsible for the cost? Who will ensure that the
standard of safety is acceptable? What does the reference to care
outside hospital, such as dental care, mean? Are we to assume that,
even though the national health service is losing large numbers of
dental practices, it will be possible for dentists on the continent not
only to treat British nationals, but to charge for that work? This is
only the beginning, Dr. McCrea, but I interpret your sensible
movements to mean that I must not push my luck too
far.
Ms
Winterton:
On the transfer of health-related data, I think
that we would all accept that if a patient were to gain permission from
a PCT to go abroad for treatment, the data should be transferred to
help the operation to take place. There would be a need to know the
patients medical history, for example.
The cost of going abroad for
treatment without referrals is exactly the problem that we are trying
to overcome. That is the kind of thing that would prevent us from
properly planning our health service, which is why we want to build
into legislation the principle that the normal referral practice of the
country concerned must be followed. If it is necessary to get a
referral from a GP to go into hospital in the UK, that process would be
followed if a patient were to request treatment
abroad.
Mrs.
Dunwoody:
Would that be influenced by a timeline? If the
local district hospital was unable to perform a particular operation
within a certain time limit, for example, would that open the door for
an individual to go elsewhere and claim an urgent need for
treatment?
Ms
Winterton:
I was just about to come to that. We want to
achieve a positionthis relates to the Watts casewhereby
the PCT would be forced to grant an individuals request for
treatment abroad only if an NHS clinician considered that there was an
undue delay. If the treatment could not be provided locally or anywhere
else in the country under the choose-and-book system and the clinician
said that there would be an undue delay, the PCT would have to accede
to a request to go abroad for treatment. My hon. Friend will know that
it is possible for a PCT to send a patient abroad if it so chooses, but
we are trying to clarify the point at which it is forced to do
so.
Mrs.
Dunwoody:
I am grateful to my hon. Friend for her
indulgence. She will be aware that British nationals who have worked
abroad and not contributed to the national insurance scheme in the last
two years frequently find themselves unable to receive NHS treatment
without being charged very large sums for it. Am I to take it that
these changes would mean that even if they could not be charged under
existing NHS regulations, if they were British nationals and therefore
part of the European Union, they could nevertheless receive that
treatment free on the basis of it being available to European citizens,
or are we to assume that they would still be regarded as exceptions to
the
rule?
Ms
Winterton:
I will write to Committee members if I have
mistaken the matter, but I thought that the issue of people not being
able to receive treatment concerned whether they were resident outside
the European Union. The current system in the European Union is that
through the EHIC form, anybody who becomes ill whilst working abroad or
on holiday can receive treatment in a European country. If somebody is
permanently resident, and we have a reciprocal arrangement with that
country, such as if somebody is on holiday in Germany and breaks their
leg skiingif people can ski in Germany; I am not quite
surethey will receive treatment there. Such treatment matches
the payment systems of the country involved. The same would apply to a
German in the
UK.
There
are three countriesFrance, Spain and Irelandwhere
people live permanently, including many pensioners, with which we have
an arrangement whereby we pay for treatment. We spend some £500
million overall to support those health care systems, and that system
would continue.
On the point that my hon. Friend made about the
responsibility for standards of safety, we think that it is important
to make it clear to people that we can do a certain amount on the
European level to look at the issue of safetyin one country,
they might mark the leg to be chopped off, and in another, they might
mark the leg not to be chopped offand ensure that there is
consistency in medical procedures. However, we must make it clear that
if a person chooses to have treatment abroad, that countrys
standards would apply. With regard to redress, an individual would have
to accept that they were buying into another countrys system.
The UK would not be responsible for other health care systems and
anything that might go wrong during the course of treatment
abroad.
Mrs.
Dunwoody:
On this narrow point, would that also be the
case if, in effect, a PCT had given consent to the movement abroad of a
patient? I think that that is a sensible argument, but how would it
stand up legally if a PCT had taken responsibility for allowing the
patient to go abroad?
Ms
Winterton:
That is exactly why we want to enshrine that in
legislation. My hon. Friend is absolutely right to say that there are
areas of ambiguity. That is why we have to be absolutely clear about
the responsibilities that member states have for managing their own
health care and redress systems. If a patient decides that because of
the speed with which they require an operation, they want to go
elsewhere, that has implications, in the same way as there are
implications to a certain extent for aftercare. It is also important to
remember that patients would be told that they would be reimbursed for
the cost of the treatment that would take place in the UK, including a
visit by a district nurse if that was to happen in another country. It
would be for the individual to realise what they would be reimbursed
for.
Several
hon. Members
rose
The
Chairman:
Order. We have to try to have briefer questions
and briefer answers because quite a number of Members want to get in
and a number of questions are still to be asked. I will try to get in
as many questions as
possible.
Dr.
John Pugh (Southport) (LD): I shall be brief. I picked out
the words proportionate,
sustainable,
referral according to member
state rules
and
prioritising domestic patients. I began to think that
this piece of European legislation would even pass the Daily Mail
test. That may be an extreme
remark.
May I go back
to the fundamental principles, some of which have been covered? An
axiomatic principle of this legislation is that there is no such thing
as a free ride in Europe. The host countrys costs will always
in principle be recoverable in full. I also understood the Minister to
say that if a host country provides health care that is judged below
standard by the standards of the home country, that is at the
patients risk and there are no grounds for complaint
subsequently. If there is a definite failure in any country or in any
system, where is that established? Would it be established back in the
host country or would it be established in the home country and who
then compensates?
May I add to
that a further question about standardisation and uniformity? Health
care providers across Europe have different standards of clinical
governance. Clearly what meets the standards of clinical governance in,
say, Bulgaria may not be satisfactory in the UK. Therefore would a
Bulgarian provider need to pass further tests in order to satisfy
clinical governance requirements within the
UK?
Ms
Winterton:
Perhaps I should clarify the issue of
complaints and standards. The difference here is that if a PCT
commissions care and it decides to have 100 of its hip operations
carried out in a French clinic, it would retain a duty of care over
those operations. If it accedes to a request by a patient to have
treatment elsewhere it is the patient who is taking the risk and he or
she would go through the redress procedures in the home country. That
is what we are arguing for.
Mrs.
Dunwoody:
Would not any patient finding themselves in that
situation simply go back to the ECJ? The ECJ has made it very clear
through all the consultation documents before us that this is not a
matter of health care, but of freedom of movement and money. This is
the entire basis of the documents and the consultation. Would it not be
therefore open to any patient finding themselves in that situation
simply to take the United Kingdom back to the
Court?
Ms
Winterton:
We have to distinguish between what we want to
argue for in future legislation, the principles we want it to include,
and our ability to respond to the Commissions consultation
document accordingly. That is why we say that these are the principles
that we believe are right so that we do not continue to be in our
present rather ambiguous position. There are some things in the
Commissions document with which we do not agree and we shall
obviously be making that clear in our response to it. We have
undertaken work on the common values and principles and want to achieve
a position in which we can say what principles we think should apply
and argue in respect of
them.
There is scope
for co-operation at European level on clinical governance. One of the
areas that we consider to be important in respect of increased
co-operation might be information passed about professionals who may
work in different countries and any proceedings that might have been
taken against them, so that patients and others have such information
to hand. The movement of health care professionals ensures such
co-operation when it comes to patient
safety.
Mr.
O'Brien:
On a point of order, Dr. McCrea. In light of what
the Minister just said, it suddenly occurs to me that we need some
guidance to clarify the position if, on presentation of the motion, we
voted against it and were successful. What would happen to the current
process and the consultation that is meant to end this month? It would
provide backbone to the Minister in discussions to which she has
referred. We would welcome her being successful in discussions with the
European institutions, but if she were not we would want the
opportunity to give her more
backbone.
Mrs.
Dunwoody:
Forgive me, Dr. McCrea, I am not in any way
seeking to usurp your responsibilities. Had the Committee decided to
put down a handwritten
amendment, had it been accepted by the Chair and had it been voted on,
it would have been possible for us to go ahead. Indeed, if you check
the rules of the Committee it is clear that we shall not be able to do
that. I certainly cannot because I am not an official member of the
Committee. Furthermore, I am always so quiet that no one notices when I
am here. It is not possible for us to go ahead on the basis that the
hon. Gentleman mentioned.
The
Chairman:
It is possible for hon. Members to vote against
the motion, which is to take note of the document. If they vote against
it, it is up to them. Can the proceedings continue? Quite a few hon.
Members want to
speak.
Jane
Kennedy (Liverpool, Wavertree) (Lab): I think that, at
what seems to be an early stage in the discussions between Governments
and the Commission, we should do precisely what the hon. Gentleman is
suggesting and reinforce our worries to the Minister. For example, we
are discussing the preliminary to legislation. I would be much happier
if my right hon. Friend can reassure me about matters. She talked about
the need to clarify the right of member states to operate their own
health systems. I want her to be more robust on that and to insist that
it is the British position that the health system that we operate is a
matter for member states; and that where clarity is being sought, it is
only on the narrowest detail, of the kind that my hon. Friend the
Member for Crewe and Nantwich has been
proposing.
For
example, question 8
asks,
in what ways
should European action help support the health
systems?
It is entirely
proper that we should, within the NHS, look to co-operate with other
health systems in Europe on research and rare illnesses. It would not
be proper for the European Commission to seek to take on a role in
directing or managing that process. Free-flowing co-operation between
professionals would be very much more productive than anything that the
European Commission might want to bring
about.
Ms
Winterton:
As always, my right hon. Friend is absolutely
right. She has a lot of experience of the presidency, especially on
patient safety and other issues on which we have considered whether
co-operation would be helpful. Issues also arose during the presidency
about exchange of best practice in areas such as public health and
mental health. That has been good, in that it has enabled professionals
and others to learn from each other.
It is important to remember
that it is essential for us to have political consensus on this. As my
right hon. Friend said, that sends out the message that we are clear
that we want the right to run our own health service. That is probably
more important in the case of our health service, which is funded
through taxes, than it is for those of other member states, so our need
to make that point is more acute than others might think. That is why
we tried to establish common values and principles to which all
countries could sign up and with
which they would feel comfortable; it is the basis on which we have been
working to get consensus across member states. We shall insist on
retaining it, although some states might not attach as much importance
to the matter as we do.
Mr.
O'Brien:
I indicated earlier that I had several sets of
questions. This has been a fascinating exchange and I am grateful to
other hon. Members for having touched on this matter, enabling my
contribution to be a bit briefer.
My first set
of questions to the Minister was about whether there was potential for
a pan-European health service, and a further question arises from her
answers. Even if there is to be European co-operation only on limited
issues and, if I understand her correctly, the autonomy of member
states is guaranteed, we still need some assurances from her.
It would appear from page 24 of our documentation that the consultation
found that no legislation can offer a mechanism for keeping instruments
and laws up to date. As legislation is necessarily slow, and health
service reform and restructuringparticularly under this
Governments policiesis fast, it appears that the
consultation is pushing for the creation of a central bureaucracy. I
hope that the Minister will give us some reassurance about
that.
In the
interests of time, let me link my remaining questions to my first
remark. Can the Minister reassure us on the importance to UK plc of
ensuring that our centres of excellence are not forced to move to other
European states? How will she ensure that UK intellectual property is
safeguarded? Will we be forced to regionalise the way in which the
national health service is run in order to satisfy EU bureaucracy,
which would seem to be implied by some of the provisions that are
envisaged?
Ms
Winterton:
I am not sure that I understand the
regionalisation point. Perhaps we can come back to that. I did refer to
the possibility that under rare conditions some centres already
co-operate. I believe that there has been some co-operation with the
Netherlandsthere is a centre there with which there has been a
certain amount of co-operationbut that is about it. We want to
be responsible for organising our health services. We need to reflect
in our legislation the principles of the recommendations, not every
detail. I cannot see where a huge central bureaucracy comes into it. If
the hon. Gentleman means such matters as intellectual property, that is
currently governed at EU level but within that structure the health
services take responsibility. There is no doubt that the centres of
excellence that we have for cancer or heart disease will remain in the
UK. I see no reason why there should be any change in such
provisions.
Dr.
Pugh:
May I follow up on a couple of questions? Page 7 of
the document states that the EU wants interoperability of data systems,
and we are currently considering the evolution of connecting for health
in this country. Attached to such systems are strong confidentiality
protocols. Will the Minister explain how those will apply when we share
data with clinics in Paris as well as those in Rotherham and elsewhere
in the UK?
Following on from the matter of
the intellectual property of drugs companies and so on, there are other
issues related to pharmacy. The ambition of a Eurocrat would be to have
uniformity in prescription rules, to which we in this country would not
warm. For example, if there was greater uniformity and agreement, could
non-NICE drugs be obtained abroad and the fee charged to the NHS, or
could drugs considered safe in one part of Europe be banned elsewhere?
There are different views on the efficacy and safety of certain drugs,
and I wonder in what direction we are travelling on the
matter.
Ms
Winterton:
Again, I return to how we envisage treatment
taking place when there is a request from a patient to be treated in
another member state, to which a PCT must accede. It does not mean that
somebody will be able to purchase drugs abroad and charge the NHS. Such
issues are why we are discussing prior authorisation and how to set up
a system whereby specific permission has to be given for any such
health activity.
On
the exchange of health data, although there may be some occasions when
that is necessary to facilitate treatment, it is important to realise
that there are practical considerations. We would need to know that
there was a real need to exchange data for the safety of a patient, and
consent and confidentiality will remain paramount. We must also
remember that patient notes written in one language might not
necessarily be intelligible to someone who speaks another. There is no
locus for creating a compulsory
database.
Dr.
Pugh:
Page 7 is essentially on interoperability, which the
Minister has partly covered. We have a rather peculiar system in this
country for fixing the price of drugs, which differs from that in
Europe and can lead to sharp differences in the price of certain drugs.
Does the Minister suppose that that system whereby the NHS and the
drugs companies fix prices will survive legislation such as that
anticipated by the
EU?
Ms
Winterton:
Yes, I do. There is currently EU-wide licensing
of pharmaceuticals, but pricing issues are for individual member states
to
decide.
Mrs.
Dunwoody:
May I therefore draw my right hon. Friends
attention to this statement which he says has been agreed by the
common values and principles. It makes it very clear
that there are practical ways in which values and principles become
reality and that they vary significantly. The decisions about
the basket of health care, to which people are entitled and the
mechanismsit goes on to make it clear that it is talking about
market mechanismsare fundamentally different from those
principles which apply in this country. There is also a fundamental
dichotomy, for which I would like an explanation. On the one hand, in
the European document:
The right of all EU
citizens to confidentiality of personal information is recognised in EU
and national legislation
but it also states, in the paragraph that
I quoted earlier, that this information can be transmitted from one
country to another.
Ms
Winterton:
We want to ensure that, if that was going to
happen, the important principles of consent and confidentiality would
remain and that it would be done in the interests of the patient. There
are issues whereby anonymised information might be transferred, for
example with regard to public health or demographic profiles and so on,
but I cannot envisage the circumstances where we would want, without
the consent of the patient, to transfer information about an individual
unless it was going to actually assist them in some kind of medical
procedure.
Mr.
O'Brien:
Referring specifically to the ECJ ruling and the
distinction that the Minister quite properly drew our attention to
between hospital and non-hospital care and the two categories that
require or do not require prior authorisation, could the Minister tell
us whether audiology, podiatry, digital retinopathy and physiotherapy
count as non-hospital care to which a person is entitled in the UK, or
are they hospital care? If so, what is the medically acceptable time
limit for their treatment? Likewise, does fertility treatment come
under that latter category? While on the question of inclusion, because
of the ECJ ruling, how does this apply to social care, especially in
relation to countries that deem aspects of care that we would call
social care to be health care? That leads to the subsequent question:
how will the Minister ensure that the NHS is always paid at least a
tariff price plus any extra costs associated with the complexities of
cross-border health care?
Ms
Winterton:
I will try to answer as many of the hon.
Gentlemans questions as possible but he may have to come back
to me as I do not have all of them.
Regarding hospital or
non-hospital care, that is exactly why we do need to have some
clarification in this area. Increasingly we are seeing a number of
services performed outside hospitals that might traditionally have been
done in a hospital setting. There is a great deal of confusion around
this. For example, we do have an issue with the Commission whereby the
communication says that patients can access non-hospital care without
prior authorisation. The Commission says that that is what the Court
has said. We disagree with that profoundly and we will be saying so in
our response.
What we
believe the Court has said is that it has not yet seen a justification
for prior authorisation of primary care but it has not ruled it out. I
think that was the Muller-FaurÃ(c) case. This is exactly why we
have said that we want to see a clarification in some of these
areas.
The hon.
Gentleman also asked whether there was agreement on what would be an
unacceptable delay for individual treatments. We do not believe that it
is possible to try to achieve an overall clinical judgment that would
extend across the EU for those types of decisions, because that would
lead us down exactly the path that we do not wish to follow. If we
tried to dictate a Europe-wide agreement on what constituted an undue
delay for particular treatments, that would cause precisely the
disruption that we want to avoid. Hence we have made it clear that the
decision on when individuals need treatment should be made by the
clinician from the country concerned, not by some
other body. If the hon. Gentleman was suggesting that that should be
done on a European level, I can say that that is not the direction that
we want to take.
On
social care, the discussions that people would have are of the kind
that should take place with a PCT, because the hon. Gentleman is right
to say that in some countries a certain type of treatment
X might be considered nursing care or alternatively
social care. We would have to be clear that reimbursement would relate
first to the cost of the procedure within a member state, and that what
would be expected within a member state would come second. As I have
said, if the service were a health care service in relation to which
one would receive a visit from a district nurse, that may be covered,
but it would relate to the cost of what would happen in an individual
member state. There should not be billing from elsewhere on a whole
range of activities that a PCT may not have agreed to. That is why we
need to be clear that the principles of treatment applying in an
individual member state should be the decider in the treatment that
patients can expectif they want to insist on treatment in
another member
state.
Mrs.
Dunwoody:
Before she sits down, will the Minister indicate
the time scale? The motion on the paper is a take note
motion, and we know that what happens with them is that they go back
down to the Floor of the House without debate. Will she undertake,
before she sits down, that as the discussion is a continuing one, not
only will she give the House up-to-date accounts of what she is doing
and of the future negotiations, but matters will be debated on the
Floor of the House? The future of the national health service is far
too important to be leached away by a series of unacceptable
directives. I am only asking questions,
however.
The
Chairman:
Before the Minister responds, the hour allowed
for questions is almost over. It appears, however, that a number of
questions remain to be asked. Under the provisions of Standing Order
119(7), therefore, I shall extend the time to allow further questions
to be asked. We shall then proceed to the debate after no more than an
hour and a half. Any extra time given to questions is, of course, taken
out of the time for debate, because we must finish no later than 7
pm.
Ms
Winterton:
My hon. Friend is right that there will, I
suspect, be a great deal of interest in the area. That is why the
European Scrutiny Committee wanted the
debate.
The Commission
is going through the consultation process, and we shall send our
response at the end of January. We expect that the Commission will
publish its formal response within two to three months, and legislative
proposals will follow at some point in 2007. Because of the co-decision
procedure, any legislative proposal will have to go through the Council
of Ministers and the European Parliament. The Commission has not yet
said whether it will produce a regulation or a directive. If the
proposals are wide-ranging, we would want to see them in the form of a
directive, so that they can be put before Parliament for discussion. We
expect that to be so. From this Parliament, we are trying to make it
clear that we want to keep the principle of member states running their
own health systems.
Mr.
O'Brien:
Just for the record, the Minister covered the
social care point, though there will be some serious worries about the
interpretation abroad of what we in this country would call continuing
care and social care. I was hoping that she would respond on the issues
of audiology, podiatry, digital retinopathy and physiotherapy. It is
important that we understand what is happening in those areas as they
are becoming increasingly relevant in an ageing
population
Mrs.
Dunwoody:
Expensive.
Mr.
O'Brien:
And expensive, as the hon. Lady says from her
sedentary position. I have a simple question. What guarantees can the
Minister give that UK research, health care services and taxpayer funds
will not be used to bail out health care systems in other member
states?
Ms
Winterton:
With regard to audiology, podiatry and
physiotherapy
Mr.
O'Brien:
And digital
retinopathy.
Ms
Winterton:
and digital retinopathy, a few of those
treatments are provided on an ongoing basis. I am curious because
hurtling backwards and forwards on the issues may become a bit
ludicrous.
Mrs.
Dunwoody:
The Minister is aware that large numbers of
people are able to obtain assistance for cataracts with laser surgery
through the NHS, but it is possible that there will be waiting lists
from time to time. What concerns us is that people should suddenly have
the right to go elsewhere without the protection they can expect in
this country. Almost inevitably, the result will be that people in the
NHS have to tidy up the mess when such people come home. But I do not
want to be thought prejudiced.
Ms
Winterton:
Again, that is exactly why we want to see a
proper authorisation process. Under the circumstances that we wish to
arrange with legislation, it would be for a primary care trust to
provide authorisation if somebody requested a treatment and the PCT had
to provide it. If an NHS clinician said that there was going to be a
serious undue delay to a persons treatment, there would be a
discussion about that person being able to access treatment elsewhere.
I am slightly concerned about the practicalities of providing a
treatment such as podiatry on an ongoing basis. I am not sure that the
treatment is one that patients would say that they wanted to receive
elsewhere.
In 2005,
only 250 people accessed care in another member state. People want
their health services, particularly the treatments referred to,
provided closer to home.
Mr.
O'Brien:
As a subset of the same question, what the hon.
Member for Crewe and Nantwich and I have been driving at is that
inevitably a lot of attention will be paid to this and we hope that
there will be accountability throughout the negotiations conducted by
the Minister. However, one obvious consequence is that large numbers of
people will see exciting opportunities to compare availability here
with that in other member states and think about what might be
encouraged. Therefore, we need to define true rights and entitlements
and how that affects both our ability to control and be accountable for
the health service in this country. We also need to make sure that we
do not damage it either by leaching one way or by having to pay for
things in the other
direction.
Ms
Winterton:
That is exactly why we want some of the
principles in the legislation to address the fact that people can
request treatment elsewhere that is the same as that provided by their
PCT. A person cannot demand treatment elsewhere that is not provided by
the NHS. We want to be very clear on that principle. There has to be
prior authorisation for the treatment and it has to be something that
is provided within the member states health care system.
Reimbursement would be at the cost of that treatment in the member
state. There is nothing in the provision that says that one member
state will bail out another facing problems with its health
service.
Mr.
O'Brien:
I am grateful for that. What has become clear
from the Ministers answers is that quite understandably and
totally appropriately, the Government, suddenly faced with the prospect
of having to fix this problem, are bringing forward these proposals,
and we are dependent on the successful outcome of the negotiations that
Ministers will undertake and in which they will hopefully
succeed.
We have been
fortunate in genuine emphasis being given to retaining domestic control
of our health service. However, we have had the prospect over many
years of a questionable approach to and a lack of success in the food
supplements area, which has caused anxiety over many years. That has
now moved to a different phase, or we would like to think it has in
recent times. Therefore it is fair to ask the Minister what prospects
does she feel she has, what allies has she already established, what
discussions is she having with equivalent Ministers in other member
states to give her confidence that the Governments stance can
succeed in these negotiations. Without her satisfactory answer, it is
incumbent upon us to find ways of helping her in those negotiations.
Otherwise, we all face being dragged down by the same
problem.
Ms
Winterton:
It is encouraging that, through the Council of
Ministers, we have been able to achieve common values and principles.
We have been successful in making the Commission aware that this is
something that the Council of Ministers has agreed to. The
Commissions reference to that in its consultation document has
been important in shaping the debate, and because of the way our health
system is funded, we have an interest in that. It has been important to
engage other member states in the debate, to get their support and we
have been able to do that. However, as
I have said before, an important part of that is
sending a clear message from this Parliament that there is agreement
and that the approach does have widespread
support.
Mr.
O'Brien:
I am just getting used to this unusual process,
Dr.
McCrea.
Mr.
Clive Betts (Sheffield, Attercliffe) (Lab): Too used to
it.
Mr.
O'Brien:
I am so glad to find that the hon. Gentleman is
alive.
I am grateful
to the Minister. We need to ensure that these Committee proceedings,
the approach of the House to this matter and the Governments
transparency in trying to fix this problem are circulated as part of
the briefing paper, so that they can help officials dealing with a
European Commission decision, in reinforcing the Ministers
view, to understand the questions and concerns that have been raised in
this question sessionwhether or not we proceed to debate the
matter
afterwards.
There is a
further question to consider, which was touched on by the hon. Member
for Crewe and Nantwich and is encompassed in the documents with which
we have been provided, about the European e-health area and the
communications and disclosures that surround it. Although the Minister
has given some answers on that already, I am worried that the
connecting for health programme does not appear to be geared up to join
the European e-health area. Perhaps she could mention how much capacity
she thinks there is in the connecting for health programme at the
moment, given all the other concerns that there have been with it.
Also, where does the more recent climb-down on patient records and the
opt-in/opt-out discussion sit with giving Europe-wide access to our
medical
records?
Ms
Winterton:
I beg the Committees indulgence. I do
not know the up-to-date position with regard to connecting for health
and the implications of how that would feed into the e-health area. I
should like to write to members of this Committee and the Scrutiny
Committee to address that, because if I tried to do so now my answer
would not be as full as it could be. As hon. Members have said, there
are some important issues about confidentiality and so on. If it is
acceptable for me to write to Committee members, it would be a more
useful way to approach the
matter.
Mr.
O'Brien:
That would be fine, providing a document is
attached to the papers that are available with this package in the
Table Office. Any hon. Member seeking to understand the full
ramifications should have that explanation on the
record.
Dr.
Pugh:
Two aspects regard interoperability: who has access
to the information and how. If it is ever going to happen and if it is
ever going to be useful to us for our records to be known about in
Paris as well as in Rotherham, we will need systems. Actually, we are
more likely to have accidents in Paris than Rotherham, so it is
important that the systems can speak to one another. Therefore, the
systems design needs to be taken into account. That is beyond
the Ministers remit.
Dr.
Pugh:
Any information on that would be
helpful.
Ms
Winterton:
For me to venture comment on the design of IT
systems at this point would be rather above my station. Of course, I
shall try to address those points in a
letter.
Mr.
O'Brien:
The Minister rightly moves swiftly away from that
point, leaving it for a future draft. I hope she is able to command
someone else to prepare the first draft. I put my question on the
record in the hope that it would be helpful. I hope that we will learn
whether Her Majestys Government have it in mind to lobby for a
central European spine through the interoperability standards or is a
European health card is envisaged that would transfer health-related
data? That issue is important particularly if we bear in mind the
recent controversies in this country in relation to patient records and
identity cards.
One
final area for questioning relates to a point that I raised earlier
about the ramifications of this measure, which could affect our
world-class, competitive biotech industry and result in an essential
pull to the research and development base, which is so competitive, not
least in the north-west which is represented by a number of Members
present. Has the Minister been able to develop assurances over
particular concerns, where EU ethical decisions could override UK
ones?
Let us not beat
about the bush, euthanasia is an obvious source of controversy.
Euthanasia, in certain circumstances, is permitted in some other member
states. [Interruption.] There is the issue of stem
cellsthat was a welcome prompt from a sedentary position, but
it was on my mind. I have been to the research triangle in North
Carolina and been given a lecture about our competitiveness in
pharmaceutical and biotech. However, because of political decisions
taken in America, we have ended up with a world-class and world-beating
No. 1 position in certain areas of genetic-based biotech. We need to be
clear that the EU interlinkage envisaged will not have any diminishing,
constraining, legislative or penal effect upon the competitiveness that
we have developed in this country within the framework of ethical
standards defined through Parliament and other accountabilities. I hope
that the Minister is able to assure us, and has discussed with the
industry and Ministers in the Department of Trade and Industry, that
whatever it takes will be done to ensure that there is no danger of the
proposal impacting on the fundamental competitiveness of our
country.
Ms
Winterton:
I absolutely agree with the hon. Gentleman that
the industry is extremely important, particularly, as I said before, in
terms of intellectual property, which is managed at an EU level. Issues
of competitiveness are also extremely important.
Decisions on ethics are for
member states and the hon. Gentleman mentioned a particular issue.
There is no EU locus. In fact, the treaty article on health protects
ethical issues. I hope that is helpful, although I suspect that my
right hon. Friend the Member for Liverpool, Wavertree, who did a lot of
work on this
subject in her time as a Health Minister, is far better qualified to
speak. That is the broad basis of how we see the areas touched here.
Essentially, that is something for member
states.
The
Chairman:
If no more members wish to ask questions, we now
proceed to the debate on the
motion.
Motion
made, and Question
proposed,
That the
Committee takes note of European Union Document No. SEC(06) 1195/4,
Commission Communication: Consultation on Community Action on Health
Services; notes that this document concerns itself primarily with the
need for the development of legal certainty in the field of
cross-border healthcare; notes that this need arises from case law
developed in the European Court of Justice that currently applies to
the UK and which contains unhelpful areas of ambiguity; further notes
that the rest of the Communication looks broadly at non-regulatory
areas where co-operation at a European level may add value to Member
states efforts in the field of healthcare; and therefore
supports the Governments position that the UK should
pro-actively engage in this area in order to achieve the maximum
influence over the shape of the debate and any subsequent
proposals.[Ms Rosie
Winterton.]
5.48
pm
Mr.
O'Brien:
In the light of the extended question session, we
can be mercifully
brief.
I
hope that the Committee feels as I do when faced with a European
Standing Committee process on a document that always appears very dry,
and with other difficult documents to delve into. What the House is
doing in the name of democratic accountability is important,
particularly when the document is passported from the European
Commission, which is looking to consultation so that it can come to a
result. However, and most importantly, the document also relates to a
creature that we equally are responsible for setting up and that
affects the sovereignty of the House and its Members
privileges. That creature is the European Court of Justice. As
fundamental believers in the rule of law, the judgments of that court
cannot simply and lightly be dismissed. Any responsible Government, as
this one have shown, must therefore deal with the consequences of a
totally legitimate body of
justiciability.
I have
read the documents and raised questions, but in a less ordered and
logical way than I had hoped, because of the need to keep to one
question at a timean interesting process. Part of the debate is
recognising that the national interest is unquestionably better served
by seeking a consensual voice from Parliament to back the UKs
ministerial negotiations. Therefore, I will not vote against the
motion, which anyway, as was pointed out earlier, is only to take note.
However, what we need to do is to send the Minister off with our
anxieties, our questions and our concerns, but above all, some
backbone. It is vital that she succeeds in the areas that have been
defined, and ensures that there is no impact, nor any implication over
time, for the natural consequences, even in the minds of some
elsewhere, and even if they are unintended on this side of the channel.
We must be absolutely clear that those concerns are understood and
regarded as potential deal-breakers, given that everybody has to deal
with the ECJ ruling.
Doing nothing is not an option
and, as I said earlier, the proceedings of this Committeeeven
the words that I am speaking nowshould be before all those
who are putting together documents in member states for consideration by
officials and Ministers. Each Minister, when coming before the Council
of Ministers and the European Commissioners, should be aware of the
concerns that have been expressed and the anxieties that we have. We
have an NHS, of which we on both sides of the House are all deeply
proud. Whatever our political battles have been in the past or may be
in the future, there is consensus about a national health service for
the UK taxpayers and the national insurance-paying public on the basis
of equity of access, ensuring that it is funded by general taxation and
applies equal and high standards across the nation, without any
reference to the ability to pay. Any impact that the proposals could
possibly have on that, because of differentials in the availability,
the access or the speed of treatment in another member state should not
discourage those who have an equal stake in the UK from using the NHS,
which is not for those who might want to come and participate in it at
the expense of the general population of this country who are the
participants in and funders of it.
I hope that the more general
promises expressed during the debate will ensure that the general
principles, in addition to those enunciated by the Minister in her
opening remarkswhich I felt were wholly appropriate and started
with the principle of proportionality and sustainabilitybecome
absolutely fundamental to the negotiation. If she finds that in the
process of keeping the House fully apprised and updated, through
Library notes, written ministerial statements or, I hope, even an oral
statement to the House, she finds that she needs more backbone, she
should turn to the House to get it. There is willingness in this
Parliament to protect its rights and privileges, and we want to see the
Minister succeed. She has our blessingfor what it is
worthon the basis that a consensual Parliament in which our
concerns are well noted and well recorded is better than a fractious
one.
5.53
pm
Dr.
Pugh:
Following that benediction, I wish to point out that
only 1 per cent. of people use the services of another nation state
within the EU. However, that number is undoubtedly going to grow
significantly, so it is important that we have rules and regulations
that are proportionate to facilitate necessary and desirable
co-operation. I do not think that anybody can be against that. There is
the promise of things that we have not talked about: telemedicine,
which is mentioned in the document; pooling research, which can only be
a good thing; sharing talent; and helping people to travel and work
abroad. All those things are entirely
desirable.
There
are also obvious dangers, however, such as the abuse of the NHS. We all
support our NHS and its
fundamental principles. There is the possibility of a uniform Euro
health service, which we do not want. We hope that we can get round
Euro-restraints on NHS practice by the firm exercise of the principle
of proportionality, restraining the wildest dreams of the Eurocrats. I
think that that is what the Minister intends to do; her approach is
basically sound. We wish her luck; we hope that she has lots of
backbone; and we hope she succeeds. I want only to add that the
precedents are not promising. We have mentioned the health supplements
issue, and could also mention the working time directive. If we can do
better than that, it would be a gigantic step
forward.
5.54
pm
Ms
Winterton:
I shall be brief because I want just to thank
all hon. and right hon. Members for the questions that they have asked
in this debate. It has been extremely helpful not only in highlighting
the impertinence of the Commissions proposals but in sending a
clear message. I am grateful to all right hon. and hon. Members,
including Opposition Members, for supporting the motion. As the hon.
Members for Eddisbury and for Southport have agreed, political
consensus on the matter is important. It is particularly important for
engaging the interests of other member states.
We were successful in removing
health from the services directive. Although it involved some hefty
negotiations, they were successful, and we are pleased about that. It
is important to clear up such matters, which are ambiguous at the
moment. We have a proper process for considering them and for ensuring
in future that we can continue to plan properly and control our
national health service, which is particularly loved by the people of
this country. My backbone is stiff now. I shall disappear over the
horizon and, I hope, come back successfully with a clear message from
this
Parliament.
Question
put and agreed
to.
Resolved,
That the Committee takes note
of European Union Document No. SEC(06) 1195/4, Commission
Communication: Consultation on Community Action on Health Services;
notes that this document concerns itself primarily with the need for
the development of legal certainty in the field of cross-border
healthcare; notes that this need arises from case law developed in the
European Court of Justice that currently applies to the UK and which
contains unhelpful areas of ambiguity; further notes that the rest of
the Communication looks broadly at non-regulatory areas where
co-operation at a European level may add value to Member states
efforts in the field of healthcare; and therefore supports the
Governments position that the UK should pro-actively engage in
this area in order to achieve the maximum influence over the shape of
the debate and any subsequent
proposals.
Committee
rose at four minutes to Six
oclock.