You have probably seen comments from politicians and health officials in the UK in national papers about this. Many of those comments were made before the information was issued. Few actually read the details before foaming at the mouth that the UK was not going to pay for foreigners coming here or for UK residents going overseas.
Having studied the documents, rather than the reports or press releases about the documents, it is clear that there has been a large element of mis-reporting on this important issue.
What is it?
The EU Directive on patients rights in cross border healthcare.
The overall aim of the proposal is to ensure that there is a clear framework for cross-border healthcare within the EU.
When will it become law?
The expected date is 2011
It will only become law if the majority of the 27 EU countries agree, but as it has been in discussion since 2003, it now seems a question of when rather than if. Few countries other than the UK openly oppose it.
Can the UK opt out?
It can try to negotiate but even violently objecting to it, the UK can neither opt out nor stop it becoming law.
Why has this appeared?
There is a growing number of medical tourists who seek hospital treatment elsewhere in the European Union than their own country. Its aim is to create a formal framework for cross border healthcare and remove the obstacles that patients face if they wish to travel for treatment in other EU countries.
About 1% of operations performed in the 27 EU countries involve people from other countries.
The Directive has come about from a desire to create a European market in healthcare, and to some extent as a result of European Court judgements that have upheld the rights of patients to gain reimbursement for treatment in other countries where they have been subject to ‘undue delay’ in their own country.
Will the NHS fund health tourism?
The Department of Health says that ‘health tourism’ will not be funded by the NHS. Perhaps they should have read the details before firing off press statements.
They have inadvertently or deliberately missed the point that the new directive - the result of several years of negotiation in which the Government has been fully involved - does not confer any new rights on EU citizens to become health tourists. Nor does it impose any new costs on health systems.
It simply says what is already EU law, though now codified in a far more comprehensive fashion. People have the right to travel and to have treatment abroad. If they do so, they will be reimbursed by the exact amount that their treatment would have cost in their home country.
How will it affect UK NHS patients?
In April this year, NHS patient choice in the UK was extended, giving patients the right to opt for treatment anywhere in the UK.
The Directive extends this patient choice to anywhere in the EU, provided that the treatment is available at a cost that is the same or lower than the NHS cost. The NHS is quite expensive compared to many other EU countries.
Who will pay?
The NHS will have to set up a direct payment or reimbursement system, probably separate from local NHS trusts.
It is unclear whether patients have to pay and then reclaim, or whether there will be some form of direct billing system between hospital and health services.
It is complex as systems vary. In some countries such as France the system is that the patient pays upfront and then gets partial reimbursement from their health fund. In others such as the UK, the care is given free, except for minor charges that the patient pays for. In other countries the hospital gets paid by a semi-official health fund direct.
The most likely scenario at present is that where a private or state hospital currently demands payment direct from patients, that system must remain and anyone from the UK needs to reclaim all or part payment afterwards.
Where there is no bill to the patient, it will be up to governments to decide whether the administration involved in charging each other is worth it or not.
Some argue that as there are more likely to be more people going abroad where their NHS trust has long waiting lists or a bad local reputation, then it should be the local NHS trusts who should pay for treatment, not a central source. Otherwise the quick way to get waiting lists down and save money would be for a local trust to tell people to go overseas.
What costs will not be paid?
The NHS will not pay for travel and accommodation costs. Nor will it pay for other costs that are not medical. This is going to cause a problem in that, for example, you do not pay for your food in the UK, but in a French hospital you have to.
Is prior approval needed?
No prior approval is required from the local NHS trust.
No prior approval is needed from your GP.
After UK protests, the directive includes an opt-out clause for governments. But the wording is very clever. Governments can only seek to change the system from no prior approval to prior approval for in-patient hospital treatment. And that change is not on a case-by-case basis, but for all treatment.
The UK government cannot impose a prior approval system just because it suits politicians or the NHS. It can only do this if it can convince the EU that not having a prior approval system is detrimental to the financial stability and operating capability of the NHS. Roughly translated, to get the EU to allow prior approval it has to admit that there is a mass exodus overseas of NHS patients and that the loss of those patients is crippling the NHS. So, the government would have to admit that its much-praised NHS is not able to adequately treat customers when, where and how they want.
As much as they huff and puff about prior approval in the press, the EU drafters have effectively made this a suicide clause - the government can have prior approval only if it admits the NHS is falling apart!
What treatments are excluded?
The Directive does not apply to treatments overseas that are not covered by the NHS. So, if a new drug or a new procedure is available in another country, the patient cannot obtain payment for this.
Neither does it cover areas that the NHS does not cover such as cosmetic surgery, laser eye surgery or cosmetic dentistry.
It includes dental treatments but only as far as what the NHS provides.
It does not matter whether or not the treatment is in-patient or out-patient, hospital or clinic.
The treating centre does not have to be state run. This is because across the EU, some countries operate state healthcare, others operate private healthcare partly funded by the state.
You would only be able to access treatment currently provided in the UK, meaning that, for instance, the German practice of prescribing spa treatments to cure certain ailments will not be made available to all.
Why will patients opt for treatment abroad?
It is not just for where there is a waiting list. Patients may decide to travel abroad because:
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Surgeons and hospitals with better results for their treatment may be available elsewhere in Europe.
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Hospital infection rates may be lower in other European countries.
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Some countries have better survival and success rates for certain operations than does the UK.
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Faster treatment may be available elsewhere.
Can I jump waiting lists?
Patients cannot jump the waiting list in other countries and in some countries the waiting lists are as long or even longer than in the UK.
Information centres
All governments will have to set up national information centres, and if they want they can add regional and local ones too.
The UK national contact centre must provide information on patients’ rights to go abroad for treatment. It has to provide information on the relevant processes. It has to provide practical assistance to patients on where to go and how it works. It must provide details of how, when and what reimbursement a patient is or is not entitled to.
The centre does not have to advise on which country, hospital or clinic to go to, as the member states have to ensure that providers are clear on what they offer, the outcomes and costs.
The centre will have to have a high profile, available by phone and online. Setting up a visit only centre in the attic of Dewsbury Town Hall which is only open on every other Wednesday unless it rains, is not acceptable.
The logical method would be to expand NHS Direct.
How will I know where to go?
All countries will be forced to provide information on costs and waiting times for procedures so that patients will be able to make informed choices about their treatment.
But this is unlikely to give detailed help on which country or hospital to choose.
Basically you will have to be armed with the NHS internal cost of the procedure in the UK. You will then have to shop around to find somewhere that can do what you want when you want. If the cost is lower than the NHS, you do not keep the difference. If the cost is higher than the NHS you are responsible for the extra.
The NHS officials have failed to grasp that it could produce an army of bargain-shopping patients going overseas that could save it a lot of money!
How it could work?
Suppose a British patient decides he wants his hip implant done in Spain. If the local cost exceeds the NHS price (£5,587 for a straightforward cemented implant) he will have to pay the difference. If the cost is less, then the operation will have cost the NHS less than if he had stayed in Britain for it, and he will have reduced the queue by one.
Does it affect the European Health Insurance Card?
The scheme will differ from the European Health Insurance Card, which allows EU citizens to access free or reduced cost medical treatment that becomes necessary while they are already in another member country on holiday or on business.
What about private treatment?
The directive does not apply to private treatment in the UK.
There are many clinics offering dentistry at a fraction of the UK price. BUT it is not the UK private price that matters, but the cost of dental treatment under the NHS. That in turn does not mean what you pay the dentist, but what the dentist charges the NHS for your treatment.
The same applies to medical care. Comparisons between UK private care and overseas private care are not relevant – only how costs compare to what the NHS internal costs are.
Will it affect private medical insurance?
It may encourage UK insurers to allow people to travel overseas for treatment. But don’t hold your breath. A few very expensive policies will allow this now. The general attitude of UK insurers is summed up by the official attitude of one that says it will, if pushed, offer you a policy to cover overseas treatment. But, for the privilege of going to an overseas hospital that may be only half the UK cost, it will charge you more premium than if you buy a policy for treatment, and you have to pay your own travel costs. So the insurer saves money and you pay more to the insurer! This shows that most UK health insurers are still struggling to cope with the basic principles of medical tourism.
Will it affect the NHS?
It could reduce the burden on NHS waiting lists, and offer cost savings where cheaper treatment is available elsewhere in the EU. It could also mean that NHS hospitals would face increased competition and would have to improve their performance, as they will be judged against EU standards. A bit like the health versions of the European Cup - our footballers/hospitals are ‘world class’ – until they actually have to play against other countries!
Certain politicians rant that we will see an influx of foreigners who we will have to pay for. These remarks were made without reference to anything as boring as the facts. The relatively expensive procedures and longer waiting times mean Britain is unlikely to become an attractive choice for health tourists.
An EU national, foolishly believing the government praise of the NHS, decides he would like to come here for an operation. If the NHS cost is higher than the cost in his country of origin, he will have to fund the difference. If it is less, the NHS will be reimbursed its normal tariff cost. The NHS will have to find room for another patient, but it will have been fully reimbursed for treating him.
How many patients will opt for treatment abroad?
Government research suggests that the vast majority of patients want to receive medical treatment, particularly hospital treatment, close to home.
EU officials expect just one in 300 European patients to take advantage of the rules. The great majority will live on the mainland with attractive hospitals just over the border.
However, a recent survey by BCWA, the private medical insurer, shows that one in two Britons say they would be prepared to travel to other EU countries for medical treatment, most because they would not want to wait for the procedure on the NHS.
Andrew Haldenby from Reform, the think tank, says that huge numbers of patients could use the new laws in future, "The number of patients who know they can do this and have information about better healthcare abroad may just be hundreds now, but in five years it will be thousands and in 10 years it will be hundreds of thousands."
Much may depend on what happens to budget airfares.
What happens next?
If the majority of the 27 EU states can quickly agree the basis and iron out any problems, then there is no reason why it cannot be introduced before 2011. The opponents such as the UK may be forced to agree in principle but are quite likely to drag their heels in setting up an information centre or payment reimbursement methods. Whatever the outcome, the government and NHS will do their best to stop you going overseas for treatment they have to pay for. Expect a lot of political spin suggesting how inexpensive and efficient the NHS is compared to overseas providers – the British ability to portray foreigners as villains has not really changed since the 1930s.
Conclusions
Like it or not, we will eventually have a European Health Service rather than individual state ones. Each country will still be able to decide what it, or rather what we as taxpayers, can afford to provide and what individuals must provide. Almost all EU countries are moving to a health system that is part state funded and part private.
Health insurance: Hot Topic: July 2008
