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


Examination of Witnesses (Questions 260-279)

Ms Jo Webber, Ms Susan Williams and Mr Tim Curry

4 DECEMBER 2008

  Q260  Lord Lea of Crondall: Obviously one of the emotive questions to do with the private versus public is queue jumping. How do you get information across that you have spare capacity, that you can take a patient at that point in time? Or do you take the patient who is at the top of the queue? How does all that work?

  Mr Curry: Slowly. It is genuinely difficult. There is an issue of capacity within the NHS. Many Trusts are operating at high levels of capacity that the private sector simply would not operate at because they operate in that kind of market where they need to have flexibility to meet consumer need. The NHS is already working at 90% to 95% capacity in many cases. How do you achieve it?

  Lord Lea of Crondall: In this cross-border context.

  Chairman: I think we had better move back into Europe. I think you are asking the $50,000 question.

  Q261  Lord Lea of Crondall: No, I mentioned it in the European context.

  Mr Curry: If you look at the different healthcare systems, some which are very much driven by an insurance system where that kind of information is routinely gathered and used, that might be very simple for some countries to do because they do that anyway as part of their system for delivering care. In this country, I would suggest, it would be slightly harder, but it is something that I do believe is getting better because of the way that information is now flowing throughout the system.

  Chairman: Perhaps we could move on, because we are running very short of time, to Lord Wade and the co-operation between Member States.

  Q262  Lord Wade of Chorlton: I want to ask you a series of questions on co-operation. Could you explain to us your personal experience of existing methods of co-operation? What is your view on the draft Directive's provision for co-operation between Member States, including European reference networks? What do you consider to be the potential advantages and/or drawbacks of such provisions, and what other measures, if any, do you think should be introduced?

  Ms Webber: From a Confederation point of view, we have a great interest in the EU reference network system, particularly issues around e-health and new technologies. Our experience shows that the progress is best when it is done through specific project-based work. There is a lot of co-operation between Member States in some of these areas. This may or may not be funded through EU programmes, but obviously the EU funding streams do help some of these cross-border projects. I have to say we are not convinced of the benefits of their provisions in the draft Directive. I think one of the issues is the risk that the work gets bogged down in bureaucracy and undermines some of the existing work and puts back future development rather than enhances it. But I think there are some elements, such as prescription charges, where the recognition of these could be of benefit, particularly if you look at Northern Ireland and the border with the Republic of Ireland as well. We just feel at the moment that the project-based approach to co-operation probably gets us further than some of the provisions laid out in the draft Directive.

  Ms Williams: I would like to make some broader comments and then Tim is going to comment particularly on e-health, which is one of the areas. In terms of co-operation, I have mentioned that we have been collaborating with our sister organisations for many years and our experience of collaboration across Europe is that it can be very beneficial. In fact that collaboration began with all the work that was done around the EU Nursing Directives and mutual recognition of qualifications. We are generally in favour of organisations across Europe coming together, therefore, not necessarily to take a uniform approach but because they can learn a lot from each other. One of the issues linked to the question before around information, and particularly information around quality and outcomes, is that there needs to be an awful lot more work done in terms of collaboration across countries on quality and quality indicators. That is at a very, very early stage, and there are very, very many different systems. Again, we would not necessarily be promoting them as one-size-fits-all, but we need to accept that there is a lot more work that can be done, and, rather than that being dictated in a Directive, that is something where organisations should be encouraged to collaborate. I will hand over to Tim because we think the e-health issues are particularly significant.

  Mr Curry: I will try to be brief on this because e-health covers a range of issues, telemedicine, telecare, electronic prescriptions, electronic patient records, and that in itself is worthy of a few days' discussion. Across a European level again, we come back to the point about interoperability, that co-operation between the industry, between providers, between Member States and commissioners, will need to be really improved. Although there is already some, it needs to be improved. Making systems talk to each other, even within NHS England, has proven to be a challenge, if I might be so polite, and there will be even more significant challenges going across borders if you add to that language barriers, differential diagnoses, and different terminologies. The Royal College of Nursing released a leaflet, a very short affair, a few months back, called Make IT Safe, and there are four broad principles that we think all systems should adhere to. The first is that the systems should have within them standardised terminology. There are international standards for health, things like SNOMED CT and so on. The platform and the product itself should be acceptable to clinicians and to the public. It should be useful, not an added burden. The technology needs to be fit for purpose. It needs to be robust and not breakdown and be able to be portable and taken around. Of course it needs to be evidence-based. We need to develop systems which are based on the best evidence we have. In terms of co-operation across borders, it is absolutely essential that we learn from the best and offer that across borders, to encourage the development of good systems which can talk to each other because, at the end of the day, e-health is about improving patient safety and the quality of patient care.

Chairman: We would value you sending us a few of those leaflets, if you are able to.

  Q263  Lord Wade of Chorlton: I wonder if you have considered the longer-term implications of this Directive. What do you see happening? Quite clearly you are indicating certain co-operative activities which will probably improve and probably some which will be a bit more difficult to bring about. Do you envisage that ultimately we will find the health services throughout Europe becoming much more the same? At what level might that be likely to happen? Clearly there will be an impact of all this which is going to change the whole picture of what takes place in health care in Europe. Would you agree with that?

  Mr Curry: I would very briefly say that I doubt if the systems will ever truly become the same but I think we should agree that there are things which should become the same, the notions of safety and quality, or at least there should be benchmarks—so that we can all say that this represents quality, this is safe, this is good, this is bad. Those are the things which I think it would be good to aspire to.

  Ms Williams: I think we should also accept that whether this Directive exists or not, there is much more collaboration taking place. There is a lot more collaborative research being undertaken, not to make everyone the same but to learn from experiences in other countries. That is a reality, whether this Directive is introduced or not.

  Q264  Chairman: They are taking the best.

  Ms Williams: Yes.

  Chairman: We need to move on to this vexed question of prior authorisation and Lady Neuberger is going to probe that in a little more detail.

  Q265  Baroness Neuberger: I need to declare an interest as well, because I am a non-Executive Director of the Voluntary Health Insurance system in Ireland, which is a semi-state insurer, and obviously people come the other way, from Ireland to here, which is part of this issue. You have already said something about prior authorisation, and I suppose I would like both organisations to say what their basic view is about that, but I particularly want to pick up on the NHS Confederation's view that a recommendation should be made that all patients seeking care abroad should be subject to a prior authorisation procedure. I think that is quite interesting, particularly if it is not people who are going to be paid for by the NHS. Perhaps you could have a general canter around it and then I will pick up little bits.

  Ms Webber: As you quite rightly have said, we strongly support prior authorisation, not because this is a way of rationing the care but because this does enable people to make informed choices and it does enable people also to go into some of the quality and safety issues that have also been raised by my colleagues at the table with me. We also feel that it enables people's expectations to be realistic about what they are going to receive or not receive, and it also enables people to understand the long-term implications, particularly issues like complications arising or where treatment is—

  Q266  Baroness Neuberger: Aftercare?

  Ms Webber: Aftercare as well.

  Q267  Baroness Neuberger: Could I pick you up about realistic expectations. Do you really think there is any difference between the realistic expectations of care abroad rather than care here?

  Ms Webber: I think it has the potential to be different, because people do look at those other systems based on public information about things and think that things are going to be better elsewhere. For instance, they think that somehow MRSA is entirely an English problem and the quality is going to be better elsewhere. I think there are some expectations that do need to be met. We find the distinction between hospital and non-hospital care quite false. We believe that if you are going to have prior authorisation and an enabling of choice then that needs to be for care whether it is delivered in hospital or out of hospital.

  Q268  Baroness Neuberger: It simply does not make sense, because there is such variation across Europe as to what is done where.

  Ms Webber: Absolutely.

  Q269  Baroness Neuberger: Presumably you would say that not only is it a false distinction, but it does not tell you anything about how the systems operate in different countries.

  Ms Webber: The issue is that you can have some quite complex treatments delivered out of hospital and quite safely out of hospital.

  Q270  Baroness Neuberger: In polyclinics.

  Ms Webber: Prior authorisation just being part of hospital care does not seem a sensible way for us. We do believe also that Member States need to decide for themselves really the circumstances for those systems. We do not think that the idea of prior authorisation just being there in exceptional cases meets the needs of individual patients or the systems. We also would say that the rules need to be set out nationally, so that people understand and have some transparency of the process which they are going to go through if they choose to have their care in another EU country.

  Q271  Baroness Neuberger: Who would you expect to organise the rules of prior authorisation? Would you expect that to be the Department of Health?

  Mr Curry: I think that needs to be done on a national level.

  Ms Williams: Our view is largely similar. There are potentially constraints around European Court of Justice rulings, so there is a question about what should happen but there is also an issue about what can happen and what has already been ruled in law. There is question of interpreting those European Court of Justice rulings. The Commission has made an assumption that those Court of Justice rulings are saying that you are not required to have prior authorisation for non-hospital care, so there may be some work that needs to be done on how much leeway there is on that. That is why we have looked more at incentivising prior authorisation. That is particularly with hospital care, but, as we have said, the distinction between what is provided in a hospital and what is provided in another setting is shifting all the time. It is not even a static position, as care changes. We should be looking at encouraging patients to seek prior authorisation for all the other reasons we have mentioned, which is that there is then an opportunity for them not to have to pay upfront, they can discuss issues around continuity of care, et cetera, but it may not be possible to require prior authorisation in all circumstances. I can imagine that if somebody is accessing primary care because they happen to be abroad for two or three months, and there are small payments for that and they do not see it as practicable to come back to the UK or back to their country to seek prior authorisation, from a pragmatic point of view there seems little point in requiring it for those types of treatments.

  Q272  Baroness Neuberger: Perhaps I could just pick that up, because I think this is where it is going to be key. You are going to have people living abroad or being abroad for three months, say—and that is common. They are going to be treated in a polyclinic, say in Italy, where they are all over the place, which is not defined at the moment as a hospital. You would say that pragmatically there is not a lot you can do about that, and in a sense you probably cannot have prior authorisation. What would the Confederation's view be on that?

  Ms Webber: I think you have to have some pragmatism about this. There are some things that potentially you would get, through maybe using your EHIC when you are on holiday, for which you would not expect to have prior authorisation, but in the main, as standard procedure, we would suggest prior authorisation.

  Q273  Baroness Neuberger: For somebody who is going from A to B, as opposed to somebody who happens to be there.

  Ms Webber: Yes.

  Chairman: Lord Lea, you wanted to pursue this issue about liaison between service providers across the EU.

  Lord Lea of Crondall: Yes, I was very interested in Ms Williams referring to 30 years' experience in talking to other colleagues in Brussels and so on. I remember about 35 years ago, as a TUC official, that the RCN asked for some advice and whether we could show them around Brussels, which we did. Anyway, I do not know whether both of you would like to say what the setup in Brussels that you work within is. Secondly, in that collective body you may have agreements and disagreements. Can you tell me, are there any different points of emphasis on this? Finally—if I may trespass slightly, Chairman—I still do not understand how information is agreed on whether a bed is available—say the four months waiting for a kidney transplant here or something which we have been through in another context. Are people supposed to have beds available as a priority if it is from somebody else? How do you discuss that? I am sorry, that is a slight trespass, but it gives an illustration of what you might call—

  Q274  Chairman: Can I ask you to concentrate first of all on the question about liaison. We may come back at the end to some of the other issues.

  Ms Williams: The Royal College of Nursing is a member of several European networks but the two key ones are the one I have mentioned, the European Federation of Nurses Associations, which brings together professional and trade union nursing bodies, and also the European Federation of Public Service Unions, which is a wider collaboration of public sector trade unions, not only in health but in other areas as well. Within the discussions—because obviously there is a lot of debate going on in Brussels about this, and both of those organisations have permanent bases in Brussels with whom we liaise regularly—the key areas which we have highlighted, which are also areas that they have highlighted, are those around equity, so there are concerns about equity between socio-economic groups and the issue about upfront payments. The other one is around the importance of ensuring continuity of care and quality and safety frameworks, so not necessarily the detail of quality and safety but the need to ensure that those frameworks are in place. We should also say that there are other proposals coming out of the European Commission around patient safety and infection control, so there is a wider package of measures. One of the things that both of those European alliances have highlighted, which has not been a particular focus for us and which is also what they would see as the challenge, is the fact that they see this Directive as largely offering cross-border care more to the North and West European countries. For those in the South and Central and Eastern Europe, the costs that they would either be reimbursed or paid upfront, because healthcare costs are lower in their countries, would not cover a large amount of the treatment in North and West Europe. Our European bodies are also flagging up an inequity at that level. The other one to say about our trade union colleagues—and again that is an issue of emphasis because it is a much broader concern that they have overall—is the concern about internal market and competition policy in the European Union and the way that may impinge on public services and public service delivery in Member States. They have for a long time had a separate campaign to have a framework Directive relating to public services, so I think they would see this Directive as one element of potentially promoting internal market and free movement and competition rather than the provision of public services that are equitable for all.

  Q275  Chairman: Lord Lea, I am going to hold your other question for a moment—I know you have asked it and it is an important question—because we are running short of time. We can always do with more time when we have witnesses who are giving us good information. I am sorry, Ms Webber, is there something else you want to say?

  Ms Webber: Yes, in terms of our liaison with other EU bodies, we host the NHS European Office, which is based in Brussels and funded through the strategic health authorities. This office is the only one we know of in Brussels that represents a whole health system. It obviously gives us quite a high level of access to policymakers and we engage directly with the Commission and with European Parliament Members but we also work with relevant representative bodies, including HOPE, the European Hospital and Healthcare Federation, which has members from 32 organisations, representing 26 different EU countries and Switzerland, and obviously liaises between different healthcare systems. We do know that our views are aligned with HOPE's views in terms of the issues around prior authorisation and that HOPE has a position paper which is available on their website outlining their position on this. We also work with EHMA, the European Health Management Association, and through NHS Employers with an organisation called HOSPEEM, the Hospital and Healthcare Employers Association. Again that enables us to gauge what the views are across other Member States. Our feeling is that there are some common issues around patient information and the impact on equity that will be picked up by those organisations.

  Q276  Lord Eames: We have been talking about cross-borders and what-have-you. Now let us look at the UK. Devolution has caused as many problems as it has solved. I should declare an interest on this! It may be obvious.

  Ms Williams: In terms of our response and what we feel is appropriate from a European Directive, the main issue for us has been that as long as there are transparent systems in place about what healthcare is available in any one of the four countries and what would normally be covered for funding, and as long as those systems are transparent and accountable, then we would want to ensure that any Directive at EU level does not take away the rights of the four countries to determine how they are going to prioritise health and that there will be differences.

  Mr Curry: Could I make a very quick illustration of some of the challenges in devolution around how care is funded for within the NHS. In England we have a system called Payment by Results, a system of paying for activity really, and that has been constructed quite uniquely in NHS England. The other three countries do not use a system like that, although Northern Ireland is piloting similar approaches. We are left, therefore, with confusions about how reference costs are created or how prices are made. That has been manifest in cross-border care between England and Wales, between specialist children's services in the Welsh borders, and between Scotland and England, and between Northern Ireland and Southern Ireland as well. So, although the case-mix payment systems are common through many parts of the world, even within the UK there are substantial differences of interpretation about what is a cost and what is not a cost, what is a diagnosis and what is not, who is involved in that process and how transparent it is, and so on and so forth. Devolution has provided some difficulties there but they are not insurmountable.

  Ms Webber: We would absolutely agree that in terms of the framework the Directive needs to provide a framework but it would still be down to the local health systems. There are issues of difference between the four health systems within the devolved administrations and England. We would not want for a European Directive to make that situation more complicated than it is at the present time. Obviously the more guidance you have, the more room there is for some of those complications to take hold.

  Q277  Lord Eames: Whose responsibility do you think it should be to try to tackle some of these things? Are they more piecemeal or is there any attempt to wave a stick at everybody and say, "For goodness' sake solve these problems"?

  Ms Webber: Between the European system?

  Q278  Lord Eames: Within the UK devolved situation.

  Ms Webber: I think with devolved administrations we are always going to get differences in approach towards things. The real point is to make sure that where people live at the edge of one system, in particular, they do not get disadvantaged.

  Q279  Lord Eames: This is the point.

  Ms Webber: There has already been a lot of work between the English and the Welsh systems and I think that is where we should continue.

  Chairman: We are through the hour, but if you are happy to continue, although we will lose one or two Members because they will have to go to the next session, we would like to continue for a few minutes.



 
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