British doctors worrying about the impact of the chilly financial climate should spare a thought for their European colleagues. In Greece, the Baltic states, Spain, and Ireland, doctors, along with other public sector workers, have had their salaries and pensions cut by up to 15%, drug budgets have been reduced, and some services put on hold. Several poorer countries are also having to cope with an exodus of health professionals, exercising their right, courtesy of EU law, to quadruple their salaries by moving to work in a richer member state.
Challenged to answer the question – what is the EU doing to help your country at this difficult time – a panel of European health ministers and policy experts meeting in Venice recently looked doubtful. The message from Greece, relayed by Elias Mossialos, director of LSE Health and a Greek MP, was that the EU had failed to warn of the countries impending financial crisis. It now couldn’t provide the information needed by those trying to mandate health services in the face of massive debt. The Hungarian minister, Miklos Scocska, feared that parts of his countries health sector were in danger of collapsing and said he hoped revenue from EU structural funds could be deployed more effectively.
The meeting was held during the course of a summer school organised by the European Observatory for Health Systems and Policies (www.euro.who.int/observatory). As the week progressed, experts on EU law, health policy, and the inner workings of the European Commission explained the slow and complex evolution of EU law,* which falls into two main categories, “hard” (compulsory) and “soft” (encouraging action through jointly agreed recommendations etc). As the nuances were explained, it became apparent that the gap between what the EU currently does for health and what it might do in a Utopian future is wide; and the reasons for this are historical.
Most EU legislation which effects the health sector has been driven by the requirement to establish a free European market in goods, services, people and capital. Initially, its impact on the health sector was not forseen, or was disregarded, for the then European Community had no mandate to act on health.
Dismissing this early part of the EU’s development health’s “Roman era,” Bernard Merkel, counsellor at the European Commissions US delegation, drew attention to a couple of signal events which marked its entry into the “Middle Ages” (1986-1997). One was President Mitterand’s prostate cancer which his dynamic personal physician used as a political springboard to set up the EU’s first ever public health programme; Europe against Cancer. The second was the HIV pandemic. This woke the EU up to the need for co-ordination to fight what the Maastricht Treaty called a “major health scourges.”
But it took the BSE crisis and blood transfusion scandals to really concentrate minds. In the subsequent EU Treaty, the Treaty of Amsterdam, now replaced by the Lisbon Treaty (keep up), binding legislation on the safety of blood and blood products was introduced, a commitment made to assess the health impact of all EU policies, and a comprehensive public health strategy drawn up. Welcome to “The Enlightenment” said Merkel.
Enlightened it maybe but the European Institutions still have to skirt a fine line between allowing EU members states autonomy in how they run their health services and mounting action aimed at protecting the health and consumer rights of EU citizens.
This tension is at the heart of one of the most controversial current pieces of draft EU legislation; the directive on cross border health care.While in total, only 1% of EU citizens cross borders for treatment, it is much higher in border areas. For them, clarification of the legal position, not least on patient’s rights for reimbursement for the cost of care, will be crucial. The directive, which is anticipated to become formally adopted into EU law next year, will also increase transparency on countries differing basic baskets of care and their costs.
No attempt was made to quantify the impact of the EU on health but there were plenty of ideas on how it might do more for health. Reform of the European Medicines Agency was one, including a requirement that new medicines provide “added therapeutic value,” co-operating on health technology assessment. Another idea was to use the proportion of EU structural funds (349bn Euro for 2007-13) allocated to the health sector to improve health outcomes and tackle inequalities.
* Health systems governance in Europe: the role of EU Law and Policy, Cambridge University Press 2010. ISBN 9780521747561
Tessa Richards is an assistant editor with the BMJ.