Dawn
Primarolo: It is important that the Commission has
recognised that standards for health care should be set and should be
the highest standards. It is for member states to do that for their own
health care systems, and this Government have done
brilliantly.
Mr.
Cash: Now that the Minister has answered question No. 1, I
would like to refer to question No.
12: “What
are the implications of the draft Directive for private insurance
schemes and private
providers?”
Dawn
Primarolo: We are trying to tease out whether we
understand the extent to which other creative mechanisms might emerge
for selling private insurance products that would cut across the
principles of the NHS. I am sure that every member of the Committee
would expect us to regulate this area to protect the NHS. That is the
reason for posing the question. The answer may come back that that will
not happen, but we are posing it as an open
question.
Mr.
O’Brien: While we are discussing the impact of the
directive on private sector providers and insurers, and recognising
that even if it is limited to the publicly funded side, there is the
question of whether it will open up the treaty to Court challenges by
the private sector. Will the directive impact on the network-only
agreements held by private sector insurers? That is something with
which we are familiar in relation to the private health sector in this
country. I am referring to, for instance, the limited choice of
hospitals that can be used against a particular set of insurances. Will
we see NHS patients taking their NHS entitlement to UK private
hospitals?
Dawn
Primarolo: The hon. Gentleman’s first question
about patients’ right to choice in England is clearly
delineated, and nothing changes as a result of the proposals in the
draft directive. With regard to what the private insurance market might
do, I have to be perfectly honest and say to him that that is why we
are asking the question—we need to have some indication on that,
because it may be relevant to our negotiating position. At this point,
without having the type of information that I need from the
consultation, I am not able to answer the question in detail, but I am
happy to keep the hon. Gentleman informed.
Mr.
O’Brien: On the same subject—in effect, it
is the second part of the question—even if we put to one side
the insurance aspect, which I accept the Minister will come back to me
on, does she envisage that NHS patients will, under the directive, be
able to take their NHS entitlement to UK private hospitals? She will
accept that that would strike at the very heart of the values of the
NHS, on which we are all
agreed.
Dawn
Primarolo: No, because the directive is not about giving
new rights to anyone, including NHS
patients.
Mr.
Syms: So if someone wanted dental care, that would be
included in the scope of the measure, because dental care is provided
by the national health service. Will there be a different definition
between member states? For example, some member states may not provide
that type of service. Another issue is elective surgery that would be
provided by a state health service. That could be done within the
UK.
Dawn
Primarolo: That shows the importance of article
8 being clear. As we have explained, the measure covers hospital care
and specialist care treatment that is costly. Part of the discussion on
the directive is to ensure that that is clear, because the Court has
already limited what people are entitled to. It is not a complete
entitlement across everything that we would provide in the NHS; it
concerns specific things. That is what the discussion is about and what
we need to clarify, hence the questions in the consultation
document.
Sandra
Gidley: I have had only limited time to examine some of
the detail, but I think that I am right in saying that the prior
authorisation scheme should not constitute a means of arbitrary
discrimination, and information about the authorisation process should
be made public. Can the Minister clarify whether these are anonymised
and aggregated data, or whether individual decisions will be made
public? I am not clear on
that.
Dawn
Primarolo: I do not think that it would be about releasing
confidential patient information. By its very nature, each prior
authorisation will be done on a case-by-case basis, because it requires
the clinician to identify the clinical need and then to determine the
treatment. We have already seen that with 550 patients in the past 12
months. We would want to ensure that nothing breached patient
confidentiality. That raises issues that we have already discussed. For
example, when a patient wants to be treated elsewhere, they will have
to give us their explicit consent to send the information.
Mr.
Cash: On the confidentiality of the consultation process,
can the Minister explain the following statement in the consultation
document?
“If we
receive a request for disclosure of the information we will take full
account of your explanation, but we cannot give an assurance that
confidentiality can be maintained in all
circumstances.” In
relation to personal data, it says
that “in
most circumstances this will mean that your personal data will not be
disclosed to third parties.”
Can the Minister
explain why the matter has been dealt with in that
way?
Dawn
Primarolo: It is because there are circumstances in which
people are pursuing such a small quantity of data—we have
already experienced this in the health service—that there is a
danger of identification. What we are doing here—I really
appreciate help from hon. Members—is ensuring that we comply
with the case law without conferring any extra rights or breaching any
points of confidentiality. That is how I am trying to
proceed.
Mr.
O'Brien: Let me focus on prior authorisation, which has
been covered a tiny bit so far. During our last debate on the subject
the right hon. Member for Doncaster, Central (Ms Winterton), then a
Health Minister,
said: “We
want to achieve a position...whereby the PCT would be forced to
grant an individual’s request for treatment abroad only if an
NHS clinician considered that there was an undue delay.”
——[Official Report, European Standing
Committee, 16 January 2007; c.
8.]
The
Chairman: A question, Mr.
O’Brien?
Mr.
O'Brien: I would prefer to read the quotes because they
help to make sense of the
question.
The
Chairman: You have to ask a
question.
Mr.
O'Brien: In that case, can the Minister answer this
question? The right hon. Member for Doncaster, Central said
that “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”, and
she added
that “We
disagree with that profoundly”.——[Official
Report, European Standing Committee, 16 January 2007; c.
14.] Has
that had any impact on the draft
directive?
Dawn
Primarolo: Yes, because the section in article 6 provides
very helpful language which makes it clear that the NHS referral system
is protected. By that, I mean that the health professional determines
the clinical need of a patient and then decides on the treatment for
that individual. That is the gatekeeper mechanism that triggers whether
or not the treatment is paid for and at what
tariff.
Mr.
O'Brien: Given that the Government are seeking to protect
the principle of prior authorisation in every case, can the Minister
tell us the likelihood of that being accepted universally and say
whether other member states have said that they support the UK in that
stance in the
negotiations?
Dawn
Primarolo: These are very early days in the discussion,
but I assure the hon. Gentleman that in our discussions with other
member states, there are two principles that they are determined to
protect: that member states determine their own health systems; and
that member states, through prior authorisation, determine what would
happen outside their health system if a patient triggered the rights
set out in the legal judgments.
Mr.
O'Brien: To pursue that line, I am sure we will all be
looking for an assurance from the Government about what the directive
will do or not do in terms of seriously undermining the finances of our
health service and access to it. Does the Minister agree that, as
currently drafted, the draft directive—this is presumably
supported by the judicial history of the measure—seems to allow
prior authorisation only
where
“the consequent
outflow of patients...seriously undermines...the financial
balance of the...social security system
and/or”—
inter
alia— “the
maintenance of a balanced medical and hospital service open to all, or
the maintenance of treatment
capacity”. Does
the Minister agree that the directive will prevent the Government
applying prior authorisation in every
case?
Dawn
Primarolo: No, I do not, because the key issue will be
eligibility. Given the slightly different health systems and how they
are funded across the European Union, it is not surprising that the way
in which each member state will want prior authorisation to operate
might vary slightly. As far as I am concerned, the pressure will be to
make sure that whatever is agreed does not undermine what we consider
to be the “gatekeeper” role of a health professional
determining how someone gets treatment in the health
service.
Mr.
Cash: Will the Minister elaborate on a matter that
obviously concerns the Government too? There is a requirement for
patients to pay the costs of treatment in the EU up front and then seek
reimbursement up to the level the NHS would have paid if the patient
had been treated at home. Recognising that many people will not be able
to afford that, they must have given a lot of thought to the matter.
Will the Minister elaborate on the difficulties of many people having
enormously expensive treatment, which could arise in another member
state, and simply not having the money to pay up front? What are they
supposed to do and how is the directive going to help
them?
Dawn
Primarolo: I agree with the hon. Gentleman. That is an
important point that needs further consideration and exploration. It is
also dependent on the scale and on what is finally agreed. However, I
freely acknowledge that that is one of the matters that remain on the
table for consideration in relation to how the measure will operate in
a fair and equitable
fashion.
Mr.
Syms: On that point, how would the system work in
practice? Would it be dealt with by individual primary care trusts or
hospitals, or would it be done centrally via the national health
service? Clearly, as we have heard in the questions, this is a complex
area and there might be hundreds or thousands of people who want to
reclaim their costs. Is it practical to do that at the lowest level, or
should it be done
centrally?
Dawn
Primarolo: I do not believe there will be hundreds or
thousands or hundreds of thousands of people seeking to use the
measure; everything suggests that it will happen on a small scale. At
the moment, the view is that that aspect of the measure should be dealt
with at PCT level. We will need to keep that under consideration at the
same time as looking at the implications of the final draft text before
agreement. The hon. Gentleman is
right: these are matters that need to be considered. However, the system
is working well now and there is no reason to believe that that will
change in the
future.
Mr.
O'Brien: While we are talking about migration, I accept
that we probably will need to have the numbers that the measure will
affect. At the moment we have the Minister’s assurance, which I
fully accept at face value, that this will affect a small number of
people, but what impact will the directive have on British residents
abroad? The Minister will be aware of the recent attempt of the French
Government to withdraw health support from our citizens. Is the
directive likely to offer them more concrete protection, given the
difficulties recently experienced?
Dawn
Primarolo: The hon. Gentleman is right. This is not
connected with his point about what the French Government might have
done in terms of entitlement to treatment, but there are—I
believe we give the figure in the partial impact assessment—1.8
million Britons who live in other member states, either permanently or
temporarily. We need to be clear about exactly how many are involved,
so that has been laid out. However, not all of those people may be
eligible for NHS services and therefore for reimbursement. There is a
qualification requirement for one’s entitlement to NHS services
and that is not changed by the directive. Part of the consultation and
attempt to get the information is about understanding the scale of
that. It is possible that some people who have not been able to claim
reimbursement will now be entitled to it. It might be that they do not
have to return to the UK for treatment, as it will be paid for where
they are at the UK rate. Working out the cost to the NHS could be
complicated.
Mr.
Syms: What happens in the case of someone with dual
nationality? Suppose someone has a UK passport and a Polish
passport—presumably they would seek the full sum from the
country in which they are resident. For example, could someone resident
in London who had a Polish passport still claim back from the NHS if
they were treated in Poland?
Dawn
Primarolo: I do not think that that question is relevant.
I will go back and check it and I will explain why. The draft directive
talks about an “insured person” and imports that concept
from regulation 1408/71. Therefore, there is no further entitlement to
that which already exists. We can dream up complicated scenarios, but
it does not mean that they are relevant. I will look at the point again
but I refer the hon. Gentleman to that regulation. It is important that
the draft directive imports that definition of “insured
person” because it is already
operating.
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