La mobilité des patients[en][de] 

Health systems are primarily the responsibility of the member states, but the legal cases brought before the European Court of Justice (such as Kohll and Decker in 1998, Smits and Peerbooms, and Vanbraekel in 2001 and Müller-Fauré/van Riet, and Inizan in 2003 and most recently, in May 2006, the case of a certain Mrs Watts ) have confirmed that patients have, in certain cases, the right to access healthcare products and services in other member states with the cost being covered by their own health system.

In some instances healthcare, for example, for rare conditions or specialised treatments may be better provided in another member state. This may also be the case of border regions where the nearest appropriate facility may be in another country. 

The Council agreed  in June 2002 that there was a need to strengthen co-operation on patient mobility in order "to promote the greatest opportunities for access to health care of high quality while maintaining the financial sustainability of healthcare systems in the EU". Following Council's invitation, the Commission convened, in 2003, a 'High-Level Process of Reflection on Patient Mobility and Healthcare Developments in the EU '. 

The final session of this reflection group, composed of government ministers and a limited number of key stakeholders, produced, in December 2003, a set of recommendations on cross-border healthcare purchasing and provision, health professionals, European centres of reference, health technology assessment, information and e-health, health impact assessment and health systems, and patient safety. These recommendations were largely taken into account in the Commission's April 2004 communication  on patient mobility.

To provide clarity and legal certainty on the issue as well as support for co-operation between national health systems, the Commission has decided to establish an EU framework on healthcare services to ensure cross-border access to safe, high-quality and efficient care. A consultation regarding Community action on health services was organised in Autumn 2006 [see summary report of responses ].

Following the 2003 high-level reflection process, the Commission adopted, in April 2004, a communication  entitled Follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union. It states that "a European strategy is needed to ensure that citizens can exercise their rights to seek care in other member states if they wish, and that European co-operation can help systems to work together to better meet the challenges they face".

It highlights access to the right information regarding the quality, availability and appropriateness of different services and understanding of the procedures to be followed as prerequisites for accessing healthcare. Citizens must, therefore, be provided with a clear overview of the existing EU legal framework regarding access to healthcare and the reimbursement of the costs incurred in another member state. 

The communication sets out proposals for:

• European co-operation to enable better use of resources (rights and duties of patients, cross-border and trans-national care to share spare capacity, health professionals, European centres of reference, health technology assessment); 
• information requirements for patients, professionals and policy-makers (health systems information strategy, data protection, e-health); 
• the European contribution to health objectives (integration of health objectives into all EU policies and activities, support mechanism to support co-operation on health services and medical care); 
• responding to enlargement through investment in health and health infrastructure.

This communication is part of a wider strategy touching upon the mobility of patients. A separate communication on extending the 'open method of coordination' to healthcare and long-term care, also published in April 2004, sets out proposals for European co-ordination to support national strategies to reform and develop health and long-term care. 

Another communication from April 2004 sets out an 'e-Health action plan' within the framework of a European e-Health Area for using information and communication technologies to help improve access, quality and effectiveness for health services across the EU.

Member states' national policies are generally reluctant to authorise health care abroad. The European Court of Justice (ECJ), however, has forced them to review their position. Several Court judgements have already made the following possible:

• any non-hospital care to which one is entitled in one's home country can be sought in any other member state without prior authorisation, and be reimbursed up to the level of reimbursement provided by one's home country's system. 
• any hospital care to which one is entitled in one's home country can be sought in any other member state provided one has the authorisation of the home system. Authorisation is necessary if one's own system cannot provide care within a medically acceptable time limit considering one's medical condition. One is reimbursed at least up to the level of reimbursement provided by one's home country's system.
• those wishing to seek treatment abroad, can count on their health authorities to provide them with information on how to seek authorisation for care in another member state, the reimbursement levels that will apply and how to appeal, if they wish, against decisions.

As everybody awaits for the Commission communication regarding Community action on health services (repeatedly postponed): 

MEP Andreas Schwab  (EPP-ED/D) strictly rejects the Commission's "intransparent and misleading communication policy" with regard to the directive on health services: "It's a disgrace for Europe and the credibility of the European institutions in general, if announcements of the Commission cannot be trusted anymore", Schwab said. Yesterday [18 December 2007], representatives of the Commission had confirmed the publication of the directive on cross boarder health care. "However, this morning [19 December 2007] the announcement was postponed again. "It is very surprising that Commissioner Margot Wallström is apparently pushing for a delay of presenting the proposal. The Commissioner is arguing for stricter obligations for patients to obtain a permit for stationary treatment abroad," Schwab said. 

Some have already reacted to early draft versions:

The Platform of European Social NGOs (Social Platform) deplores that the proposed directive will deepen healthcare divide between rich and poor. "This proposed directive is made mostly for those who have the financial means to seek healthcare in another member state. Even if their health bills are reimbursed by their national healthcare system afterward, travelling patients need to pay for other expenses (travel, accommodations, translators, etc.)," said Social Platform president, Fintan Farrell, underlining it will deepen inequalities in the access to quality health and healthcare services. 

"Why does the EU directive not take account of other issues which are in the general interest of everyone living in the EU, such as equal access to affordable high quality health services for all, including particularly vulnerable groups," added Farrell.

Whereas the European Federation of Public Service Unions (EPSU) and the European Hospital and Healthcare Employers Association (HOSPEEM) argue that: 

• It is not for the European Institutions to impose market and/or competition mechanisms in the health care sector, which could have as consequence the lowering of standards and increasing costs of health care systems and thus diminishing the accessibility to care.  
• Health care should therefore be organised on the basis of common European social values including solidarity, social justice and social cohesion.  
• They should also follow the principles of general interest, like equality, accessibility and quality.  
• It is essential that EU-internal market or competition rules do not limit the EU member states' autonomy in the implementation of these national responsibilities.   

For more stakeholder positions regarding Community action on health services see individual responses to the Commission consultation. 

A public hearing on patient mobility in the EU was organised at the European Parliament in March 2005:

The MEP John Bowis said that patient mobility is about the rights of individuals. It is about "how do I as the patient, find my way through the system and what exactly are my rights now and going to be in the future" but also about "how do I as a health budget manager cope with the unplanned demand, the unplanned cost and the reimbursement procedures". He also highlights "an implied threat: that if we as politicians and governments and Commission and the Council, do not get this right, if we don’t manage to come up with a formula, then the courts will do so: they will go on doing so, and it’s a strange sort of democracy which leaves its decision-making to courts. I prefer that politicians, governments and commissions should take responsibility for policy, justify it, implement it, interpret it and we have the courts behind us, but not in front of us." 

MEP Françoise Grossetete: "What we must pursue is making sure that all European citizens when they move around the European Union can have the same guarantee of quality health care. And we haven’t achieved that yet." 

Standing Committee of European Doctors (CPME) wishes to promote optimal professional mobility through a well functioning directive on recognition of professional qualifications which it sees as a cornerstone of patient mobility. It also wishes "common standards on quality of health care, especially on patient safety" and promotes "high level of performance by all health care professionals through co-operation in the field of continuing professional development". 

The Pharmaceutical Group of the EU (PGEU) points out that the professional recognition directive covering pharmacists and doctors obliges pharmacists to dispense a prescription that has been written in another EU member state, whereas no harmonisation of format prescriptions currently exists.

The Director General of DG SANCO, Robert Madelin, said that patient mobility is first about rights, secondly about healthy life years, thirdly about money and fourthly about governance. 

Dorjan Marusic from the Slovenian Ministry of Health said that "public health care provision must be based on solidarity, equality and universal access. This is what makes a difference between public health care services and market driven health care services. What has to be avoided are negative consequences, for example in terms of the financial stability of national systems". She also said that patient mobility will lead to be better access to better health care as it will provide people with access to specialised health care. She said it will also promote competitiveness as there will be comparisons drawn between different member states, which will be "a stimulus to more rational use of staff and medical resources".

Government officials from the UK and the Netherlands said in a stakeholder meeting that they were in favour of the establishment of a 'permanent mechanism' to support EU-wide co-operation on health care and to monitor the impact of the EU on health systems, bringing forward proposals when necessary. They also said that the Health ministers should have the final say when dealing with the free movement of patients.

The International Association of Mutual Health Funds (AIM) is not convinced that patient mobility is really promoted by simply opening borders and by establishing free movement of goods and services and calls for more co-ordinated approach. "Essentially health funds are interested in two things: that is ensuring quality of care for the insured members and that it is ensuring cost-effective allocation of collected funds containing costs." 

The European Public Health Alliance (EPHA) said that the high-level reflection process was a "missed political opportunity" to re-define and increase the EU's competence in the field of health. EPHA also noted that representatives of the 'European citizen' were missing from the high-level discussions.