Journal of Public Health Advance Access originally published online on May 21, 2007
Journal of Public Health 2007 29(2):101-102; doi:10.1093/pubmed/fdm035
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Editorial |
Editorial
E G Jessop, Editor, Journal of Public Health
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European health services |
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 TOP European health services References |
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In Europe, all cows are equal but patients are not. That's an exaggeration of course, but the fact remains that the European Community, which has a common agricultural policy, lacks a common health policy. Recent judgements from the European Court of Justice have prompted the Commission to start thinking seriously about health care services.1
The Watts judgement2 was the latest in a series of decisions that has gradually taken the European project into matters of health and health care. Going ‘abroad’ is natural if you don't live on an island. The first step was taken by a Luxembourg patient who drove to his nearest optician for a pair of spectacles: the optician, as it happened, was in Germany. When the patient asked for reimbursement from his own health system, it was refused on the grounds that this audacious bid for health care abroad had not received prior authorization. The Court judged the requirement for prior authorization for a bill of about £50 to be nonsense. Since then the Court has been asked to consider hospital outpatient treatment and, now in the case of Mrs Watts, elective inpatient care. In each case the judgement has been in favour of ignoring national boundaries. But no one wants the sort of free-for-all that would wreck the ability of member states to plan and finance their own health systems.
Clinicians and researchers have already established European collaborations in a number of fields, sometimes with European funding. The European Bone Marrow Transplant Registry, for example, allows evaluation of new therapeutic approaches. The dysmorphology network allows clinicians to seek expert opinion Europe-wide on the diagnosis of rare congenital malformations.
The NHS in England, which plans and organizes services for 50 million people, is the largest health system in Europe, since in other populous countries such as Germany, Italy and Spain health is a matter for the provinces and regions. Even so, we need on rare occasions to call on facilities in other countries to treat our patients. Examples include proton therapy for chondrosarcoma of the base of the skull and PET/CT imaging of insulin-producing tumours that cause persistent hyperinsulinaemic hypoglycaemia of infancy.
So in health care we are already part of a European health system, albeit one built to date on the ‘invisible colleges’3 of clinicians and academics. These informal networks seem to work well and are valued by those who participate.
Which raises the question: Do we need the heavy hand of Brussels? Research collaborations are going well, patients' rights are being established, systems are working. Despite all of this, I would say—yes, we do have justifiable cause for concern. The existing mechanisms depend on the exercise of rights established by the Court of Justice. And in public health we know that any system based on people exercising individual rights in inherently divisive. It will inevitably privilege the well educated, the articulate, the rich and the powerful.
So it seems that we need a system that is planned and organized if we are to serve patients who are poor and weak—those most in need of our help. The question is whether this can be done without overweening bureaucracy. And here, it must be admitted, the precedents are not encouraging!
Which brings us back to cows. How best can we ensure equality of treatment for all Europeans? Our first instinct might be to shy away from the thought of having to fund the health care of all the poorer European countries. Certainly the overall level of health services is so closely tied to national wealth that total equality in health care is not achievable.
But we may be able to discern segments or categories of health care that are compatible with a Europe-wide approach. At present this seems most apt for rare disorders and complex, highly specialized treatments. Many countries in Europe—for example the Baltic states, Benelux, Malta and Cyprus—are too small to generate the caseloads needed for sustained excellence in the management of rare, complex conditions. There are, as noted above, a number of clinical networks already in existence, and there is a strong European collaboration of patients' organizations for rare diseases.4 So the Commission is proceeding cautiously to establish and evaluate some networks aimed at improving the management of rare disorders.5
This limited approach seems, for the present, the best way forward.
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References |
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TOPEuropean health servicesReferences |
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- Consultation regarding community action on health services. 1 May 2007, date last accessed. http://ec.europa.eu/health/ph_overview/co_operation/mobility/results_open_consultation_en.htm.
- Dyer C. NHS must reimburse patients treated abroad because of delays at home. BMJ (2006) 332:1175.
[Free Full Text] - Crane D. Social structure in a group of scientists: a test of the "invisible college" hypothesis. Am Sociol Rev (1969) 34:335–51.[CrossRef][Web of Science]
- The Rare Disease Patient Solidarity project RAPSODY. 1 May 2007, date last accessed. http://www.eurordis.org/article.php3?id_article=1066.
- European networks of reference for rare diseases. 1 May 2007, date last accessed. http://ec.europa.eu/health/ph_threats/non_com/rare_8_en.htm.
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