Examination of Witnesses (Questions 34-39)|
Rt Hon Dawn Primarolo, Mr Paul Whitbourn and Mr Jonathan
30 OCTOBER 2008
Q34Chairman: Minister, can I say how grateful
we are that you are taking the time to speak to us on what we
think is an extraordinarily important issue on cross-border healthcare.
You know that your predecessor Rosie Winterton came to talk to
us on the subject in January and we may or may not refer to some
of the things she said in the course of the discussion. You are
welcome to send us supplementary evidence after the session if
you so wish. We already have quite detailed written evidence from
you. When you start, could you give your official name and title
for the record. Would you now like to make an opening statement?
Ms Primarolo: Thank you very much. My
name is Dawn Primarolo and I am the Minister of State for Public
Health. I am accompanied this morning by two of my officials who
I will introduce: Jonathan Mogford, who is Head of the European
Affairs in the Department of Health, and Paul Winterbourn, who
is Head of Registration and Competition. His title has in fact
changed, but that was the one that was provided to the Committee.
I would be grateful if I could make a few opening remarks before
we turn to the questioning. I want to start by saying that I really
welcome the opportunity to have this discussion with you this
morning. The evidence from this inquiry will be very important
in how we take forward our considerations on the draft Directive.
As you will know, the draft Directive was issued in July and its
main rationalea point to which we will keep returningis
to codify ten years of European Court of Justice case law. The
case law has established that patients have, under the freedom
of the single market, a general entitlement to seek healthcare
in another Member State at the expense of their home state. The
issue of patient mobility is not a new one: there are longstanding
rules under the regulation commonly known as 1408/71 that allow
patients to access cross-border healthcare under the European
freedom of movement, and, since 1998, case law has also been developed
to allow patients access to cross-border care under Article 49;
that is, the freedom to obtain services. Obviously the impact
of these routes on the NHS to date has not been significant. I
will not go into that now, because I know you will want to explore
it, but the court has established that patients are only entitled
to reimbursement of healthcare that their home system provides.
The home health system only has to pay for the equivalent costs
of treatment in the home health system. The health system can
require patients to ask for permission before going. Thus far,
the court has held that this can be justified for services delivered
in hospitals. Where patients need to ask for permission, the court
has said that permission must be given if the home health system
cannot provide the service in a clinically justified time frame.
The Committee will also be aware that we have the Watts
case, in which clear case law has now been established for the
NHS, and that has given rise to a number of ambiguities. I know
we will come to those as well, so I am putting those aside. It
is important, of course, that patients know where they stand,
and it is also important that the NHS has clear guidance on their
duties and also how health systems can manage the impact of patient
mobility. For that reason, the Government welcome the draft Directive
as a means of codifying the situation in which we are already
expected to operate. We believe that establishing a framework
for patient mobility through the political process is preferable
to continuation of case law varying entitlements that then we
can never be clear on. Our first point is absolutely the draft
Directive has to set high level rules on patient mobility that
codify the case law. There are a number of helpful principles
that we already have. The draft Directive acknowledges that it
is Member States who run their health services. The second is
that it is for Member States to determine what healthcare they
fund. The fact that Member States control entitlement is absolutely
a key point for the UK. The third is that Member States should
only be required to reimburse treatment obtained in another Member
State up to the level that they would have paid if they had treated
the patient at home or the cost if it is lower. The fourth pointa
very important oneis the helpful recognition that Member
States can maintain referral routeswhich we call gatekeeper
routesin their health systems. That, for us, is, for example,
the requirement in the NHS that a patient is assessed by a GP
first, before referral into specialist care. These are helpful
though important principles, but that is not to say that the text
does not need further amendment, and it does. We also want to
clarify the scope of what is proposed, particularly where the
Directive suggests that committees will be established to develop
implementation measures, and, ultimately, I want to ensure that
the text allows for the development of patient mobility in a sustainable
way, that balances patients' rights with responsibilities, andit
is a very important andallows Member States the flexibility
to manage their health services. That is where we are at the beginning
of a complex process. I have tried to lay out the principles that
I will seek to pursue, building on the work of my predecessors
in this negotiation.
Q35 Chairman: Thank you very much,
Minister. You have set out very clearly some of the conflicts,
if you like, that there are between the principles and we want
to explore some of those. You have also set out, and I am not
going to repeat it, the issue of where this all comes from in
terms of the need to codify. I certainly understand a little more
why you are saying that the Government are now welcoming the Directive,
and that was not necessarily so when we saw your predecessor.
There is a greater clarity maybe about where you are going to.
That being said, the issue we would like to start with is the
level of demand you consider there to be in the UK for access
to healthcare in other EU countries. We wondered in what circumstances
this sort of service had been sought previously. What specific
problems have arisen in the UK as a result of the present uncertainty
in respect of EU citizens' rights to obtain such cross-border
healthcare and have the costs reimbursed by the Member State where
Ms Primarolo: Perhaps I could start with
demand and what we are seeing operating. Clearly there is already
movement. We haveand I always forget what it is calledwhat
used to be called the E111 (as those of us who are older will
remember) for general travel in Europe. Then there is the E112,
the 1408, which has existed since about 1972. We are already seeing
some movement, and we are doing our best, but it is not significant.
I will first give you some examples of where we think there may
be demand, and we refer to this in our partial impact assessment.
We can see that in the year 2007 approximately 550 patients were
authorised to travel under the current arrangements encompassed
in E112and I will come back in a minute to some further
breakdown I have been able to get about where they are going and
what for, although it is not totally conclusive. That number is
quite small and we have the figures for previous years as well.
We can also see that where the Health Service in the past has
provided for arrangements for patients to choose to go outside
of the UK with the treatment reimbursed, the take-up has been
very low. I would refer you to the London Patient Choice Scheme
which was run between 2002 and 2005. We were looking there at
patients who had waited longer than we would have liked them toif
I might put it delicately. They were offered the opportunity,
through the fact that we had contracts with other hospitals in
the European Union, I think primarily Belgium, to go and have
their treatment faster there. The take-up was very low. That is
showing us what we also see in patients' comments on satisfaction
or criticism of the NHS, that the overwhelming majority prefer
to be treated close to home. I think we can understand why that
would be the caseand I was going to say particularly for
the elderly, but that is true for all of usbecause of family,
recuperation, whatever. In that whole scheme we only saw about
1,000 patientsand remember we were actively trying to select.
That scheme was closed down in March 2005, because there was such
a low take-up. There was also a closer scheme, I think in the
Kent area, where there was the possibility of crossing the Channel.
Again, that was not taken up. We also seeand they are not
big figures in terms of how many we treatthat the international
passenger survey shows us there are 50,000 people who say they
are travelling for health reasons. We can absolutely understand
that health reasons would be a very wide definition when we are
just asked to say, and therefore our consultation document is
trying to tease out, first of all, how many people are travelling,
and, also, whether more wouldwhether there is a knowledge
gapif it was clearer, and what for. The last point, which
we have only just recently received, is what people are travelling
for now. We find that between January and September 2008 there
were 596 applications granted, of which 561 were maternity cases.
Also, 402 of the 596 patients were travelling to only two countries:
France and Poland. Although we would need more work, I wonder
whether that might be a reflection of young people working here
from those countries but young women wishing to return to be closer
to, primarily, her mother and the wider family network when she
gives birth; so, for instance, in that period 108 of the applications
were to France and 294 were to Poland. I do not want to put too
much on that because we cannot get any deeper into those figures.
Q36 Chairman: It is very interesting
when you look at why people are travelling.
Ms Primarolo: Indeed. I have the breakdown
and I will make it available. I only received it myself last night.
If we look to 2007, again we see a similar pattern. There were
552 applications granted and over half of those were travelling
to France or Poland. Again, interestingly enough, maternity. We
cannot break down the 2008 figures yet, but for 2007 we see that,
of all the cases travelling to France, 182, 128 were for maternity
and 54 were for specific treatments, which we will need to get
into. To Poland there were 105 for maternity and one for specific
treatment. That is the best we have at the moment.
Q37 Chairman: Minster, in relation
to that, do we have any other information that tells us whether
these were UK nationals or whether they were nationals from these
other countries, as you said, returning home? Because that is
the significant issue, is it not?
Ms Primarolo: Absolutely. That was the
crucial question that I asked. But we do not ask, for various
reasons of non discrimination, the nationality of the person who
is travelling. We establish their entitlement to NHS treatment.
I have asked a number of times how I could get some indication
and, regrettably, it is not possible. The numbers are quite small
at the moment, but part of the consultation and further work that
we will try to do is to work that out. I think it is significant
that for both French and Polish nationalities, particularly young
men and women who are coming here to work, that may be an indication.
I really need to be cautious how I put that, however, because
I do not know.
Q38 Chairman: Lord Trefgarne wants
to come in, but I just want to comment that that has a wider European
implication for healthcare, does it not, if that is the way people
are travelling? I think we need to conceptualise that.
Ms Primarolo: Yes, it shows the importance
of families, does it not? Very much, perhaps.
Q39 Lord Trefgarne: With regard to
their nationalities, I should have thought their names would have
been a bit of a clue.
Ms Primarolo: Yesunless they married
while they were here.