Health services: what future action?

(B2) Reading the summary of the consultation carried out by the European Commission on health services and certain proposals, one can only be perplexed.

1° The extent of the problems revealed affects all aspects of society: from medical liability to the framework of care planning, including information for patients and professionals. So much so that one can wonder if each of the problems dealt with would not alone merit an initiative, legislative or not, assuming that the added value of the community is proven. The construction site looks huge!

2° There is a lack of objective basic data (how many people have been treated but above all how many acts of care and for what amount, in which specialities, etc.) and of subjective data (does the population really want to access care across borders?) which makes it difficult to have an idea of ​​the needs and impact of such and such an initiative.

3° The points of view expressed clearly emerge from the Nimby syndrome (Not in my back yard: not at home). Everyone agrees that a community solution should be found to the problem he suffers but refutes such a solution for the problems he causes. Example: the risk of "importing" patients is often mentioned (as a destabilizing factor for the healthcare system, etc.), but that of "exporting" is much less so. Conversely, the question of the brain drain concerns only the countries of departure, not those of arrival. And if the professional organizations agree to raise the issue of liability, they prefer light conciliation bodies, of the Solvit network type, to settle them.

4° Finally, if certain proposals give rise to divergent opinions, which is logical, still others are rather false good ideas, impossible to implement in practice at European level (quite simply because they do not already exist at national level or are the result of outdated, Soviet-style planning).

Farewell to pessimism. Solutions can be sketched out. Haven't we found them in other areas, such as maritime transport and safety, where the same questions of responsibility, quality inspections, recognition of controls, professional skills, user information, etc. arise.

But there are still several difficulties:

1° Each decision must be weighed to the nearest millimeter as the weight of health weighs on public finances (between 10% and 20% of the budget) and the economy of each Member State (between 9 and 10% of GDP) and is experiencing sustained growth. Not regulating patient mobility or encouraging it without restraint would have an impact on public finances.

2° There is a real contradiction between the way health systems operate (planning, control of care, caregivers and patients) and the principles of freedom enshrined in European treaties. When the treaties were drawn up 50 years ago, the health care systems were organized in such a way that it seemed obvious that they escaped these rules. Today, both economic and ideological developments, enshrined in European case law, added to a certain lack of anticipation on the part of governments and the tension of social security organizations (which have often played the game of transparency and patient information very little, and have even deliberately violated European regulations) are leading to this impasse. The functioning of health systems is, by nature, anti-competitive and it must comply with rules made for the competitive sector, the right of citizens to seek treatment and of professionals to obtain payment for their acts has a limit: that of taxpayers (often the same ones) to finance it.

3° This contradiction can be seen within the Commission and the European institutions themselves
more generally. While DG Sanco conducts its consultation, DG Markt multiplies infringements in the medical field (numerus clausus or ownership of pharmacies, for example) and DG Employment continues to carry out the reform of the implementing regulation on the coordination of social security schemes. All without apparent coordination.

What priorities?
All the interest of this consultation is, therefore, to press on this type of problem, put under the bushel until the Services directive, proposed by Frits Bolkestein. Among the many proposals resulting from the consultation, let us try to identify a few main lines:

1° Patient information generates a quasi-consensus and can easily find its place in a mandatory instrument (creating an obligation to provide information on care, the conditions of care, prior authorisation, setting the rights and deadlines for appeal, a dispute resolution body). Supplemented by the European Patients' Charter, it contributes to the Europe of citizens desired by the President of the Commission.

2° The codification of the case law of the Court of Justice on the reimbursement of healthcare, already partially taken into account in the reform of the social security coordination regulation (regulation 883/04), must be supplemented by an addendum to regulation 883/04 and/or a directive or a regulation, the latter being able to specify the reasons justifying the obligation to issue prior authorization or allowing it to be refused.

3° The supervision of the freedom of establishment to provide services appears necessary, in order to avoid the influx of complaints or abuses from the Member States. This is undoubtedly the most delicate point. It could find an outlet, in the absence of a directive, in the form of guidelines.

4° A framework for the conditions for transferring patients from one Member State to another should be provided, either in the form of a directive or in the form of a framework agreement, providing for specific solutions for border areas.

5° The establishment of an open method of coordination and pilot experiments could include iSanté, research on European terminology or the establishment of reference centres.