Healthcare across EU borders: a safe framework - European Union Committee Contents


Examination of Witnesses (Questions 34-39)

Rt Hon Dawn Primarolo, Mr Paul Whitbourn and Mr Jonathan Mogford

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 rationale—a point to which we will keep returning—is 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 point—a very important one—is the helpful recognition that Member States can maintain referral routes—which we call gatekeeper routes—in 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, and—it is a very important and—allows 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 they reside?

  Ms Primarolo: Perhaps I could start with demand and what we are seeing operating. Clearly there is already movement. We have—and I always forget what it is called—what 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 E112—and 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 to—if 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 case—and I was going to say particularly for the elderly, but that is true for all of us—because of family, recuperation, whatever. In that whole scheme we only saw about 1,000 patients—and 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 see—and they are not big figures in terms of how many we treat—that 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 would—whether there is a knowledge gap—if 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: Yes—unless they married while they were here.



 
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