The European Federation of Public Service Unions (EPSU), representing 3 million health care workers, and the European Trade Union Confederation (ETUC), strongly rejected European Commission claims that trade unions were “simply against patient mobility”. The comments made on behalf of the Commissioner for the Internal Market, Fritz Bolkestein, were in reaction to the ongoing objections, of a growing number of Governments and representative organisations, to the draft directive on Services in the Internal Market [1].

“The worryingly aggressive comments on behalf of the Commissioner reflected an increasing reluctance on the part of the DG Internal Market to face the serious errors they have made, in both the drafting and tabling of this directive”, said EPSU General Secretary Carola Fischbach-Pyttel. “There comes a time when even the proudest must admit their mistakes”.

ETUC General Secretary John Monks urged the Commissioner to meet with European Trade Union leaders to discuss the draft directive at the earliest possible date.” The Commission needs to show that it is engaging in a real debate on substance, stated Mr Monks.

Services Directive damages patients’ interests.

The Commission statement asserted that Trade Union objections to the draft directive “do not take the interests of patients into account”. The opposite is the case. EPSU and ETUC are gravely concerned about the directive precisely because it damages patients’ interests.
Section 2 (Articles 9-13) of the draft directive deals with authorisations. In the context of health this is linked to Article 23 ‘Assumption of health care costs’. The draft directive has phrased the authorisation, or not, of reimbursement of health costs by the country of affiliation, in a very ambiguous manner.

EPSU and ETUC have identified a number of ways in which the current phrasing could actually increase health inequalities.

Services Directive promotes health inequalities

Up-front payment - For patients going to another member state for medical treatment, the need to pay on arrival is apparent. This excludes those patients who do not have this capacity to pay immediately.
Damaging weaker health systems - The danger arises that health care providers in member states with weaker systems will focus services on patients from financial stronger systems. The motivation will be twofold; guaranteed payment from the country of affiliation and price increase incentives to match the country of affiliation. This will have the effect of excluding the patients in the host country from the system.
Travel Expenses - nowhere in the directive (nor in the follow up to the high level reflection process on patient mobility) is reference made to how travel costs can be reimbursed. Again those without the ability to pay out of pocket, will be excluded.
Reimbursement up to level of Country of Affiliation rates - The Draft directive states that countries of affiliation will be obliged to pay to the level of the service in their own systems. This raises the possibility of patients making a profit on their medical treatment. This damages the solidarity mechanism of the country of affiliation.

EPSU and ETUC advocate that in its current form, the draft directive will actually harm patient interests as it will only succeed in introducing mobility on the bases of ability to pay and not on the basis of need.

EPSU and the ETUC also assert that the Commission is being disingenuous when it states that the directive only covers areas already open to competition. The inference is that health care systems are exempt from this. However, from the White paper on services of general interest (May 2004) it is clear that the Commission does see health as being included. In section 4.3 of the white paper entitled “Providing a clear and transparent framework for the selection of undertakings entrusted with a service of general interest”, the first paragraph states that “ providers of services of general economic interest, including in-house providers, are undertakings and therefore subject to the competition rules of the treaty ”. The legal basis for this assumption is unclear and could have a significant impact on the status of hospitals as services of general interest. The lack of co-ordination within the Commission is again there for all to see.

The Commission has also attempted to retrospectively apply the Draft Directive on Services to the “High level reflection process on patient mobility”, despite the fact that this topic was never discussed in the 12 months this group met. The Commission follow-up communication to the process mentions the Draft Directive 5 (five) times asserting that it provides “a clear legal framework”. All evidence suggests the contrary.