Summary of the impact

Research into cross-border patient care in Europe carried out by LSHTM has contributed substantially to shaping the 2011 EU Directive on Patients' Rights in cross-border health care. The research was cited in numerous policy documents and used extensively in consultations at EU and national level, feeding into the legislative process. Influential EU officials have explicitly acknowledged the importance of the research in the political process. The research team has also advised professional bodies in the health care sector as part of the consultation process.

Underpinning research

EU citizens move across Europe with greater ease than ever before. Across much of the continent, border checks have been abolished. Budget travel, cross-border working and retirement all have implications for individual countries' health systems.

Questions around the impact of an increasingly integrated Europe on patients, providers and health systems were the focus of research carried out at LSHTM within the framework of three projects: the EU-funded Europe for Patients (e4p, 2004-2007), a multidisciplinary project involving universities in Spain, Belgium and other EU countries together with LSHTM and the London School of Economics and Political Science (LSE); the European Union Cross Border Care Collaboration (ECAB); and specific projects within the European Observatory on Health Systems and Policies, a partnership which includes EU governments as well as WHO, the European Commission, LSHTM and LSE. Key LSHTM researchers included Martin McKee, Professor of European Public Health (LSHTM since 1995, then Senior Lecturer) together with Helena Legido-Quigley and Cecile Knai (appointed Research Fellows 2010 and 2007 respectively).

Research was conducted at two levels: Europe-wide initiatives and in-depth case studies of national and cross-border policies. Findings clarified various aspects of cross-border care, including the practical implications of the legal framework at EU and national level; patterns of patient mobility, contracting arrangements, patient orientation and information, and communication between professionals; arrangements for cross-border collaboration, purchase of care abroad, and care of long-term residents; and the identification of options for primary legislation and implementation.

In 2005, McKee and colleagues comprehensively reviewed current information and issues relating to cross-border health care in Europe, including patterns of patient mobility, legal frameworks, financial implications, etc. They concluded that public authorities needed to act to put a legal and institutional framework for cross-border health care in place.^3.1

In a 2006 European Observatory output, McKee (together with co-editors from Spain and Belgium) collated practical experience of patient mobility from across Europe. Together with Legido-Quigley, he contributed a study on Ireland, using interviews with health officials on both sides of the border, which found that although there was a general presumption that people on both sides suffered from an unmet need for hospital services, mortality and utilisation data failed to confirm this.^3.2

A subsequent study (2012) found that the special needs of people retiring to other European countries were not being adequately met.^3.3 It and other work by the team concluded that a compromise was needed to ensure access to care without damaging the sustainability and integrity of national health systems.^3.4 A further European Observatory output (2008)^3.5 using a variety of methods including literature reviews, patient surveys and interviews, highlighted the need for national and European commitment to patient safety.

Drawing on evidence collected from two major projects, in 2008 Legido-Quigley and colleagues examined how quality of health care can be safeguarded across the EU.^3.6 They found that given the enormous diversity of health systems in member states, Europe-wide legislation to mandate a single approach was not realistic, and that the proposed Directive was likely to leave details of possible mechanisms to national governments.

References to the research

* All European Observatory publications are peer reviewed.

Key grants

LSHTM PI, McKee, Europe4Patients: The Future for Patients in Europe, European Commission FP6, 2/2004-1/2007, €1,499,136 (coordinator: IESE, Barcelona).

LSHTM PI, McKee, Health Research for Europe, European Commission, 6th Framework Programme, 5/2007-4/2009, €699,797 (coordinator: IESE, Barcelona).

LSHTM PI, McKee, EU Cross Border Care Collaboration (ECAB), European Commission (FP7), 3/2010-4/2013, €4,500,000 (coordinator LSE).

Details of the impact

The research was highly influential in informing the consultations and legislative process leading to the adoption of the EU Directive on Patients' Rights to Healthcare in Other European Countries. McKee and colleagues have also advised individual governments and health care professionals on cross-border patient mobility.

The European Parliament and the Council of Ministers adopted EU Directive 2011/24/EU in 2011. For the LSHTM team, this marked a milestone in a period of intensive consultation work which resulted in their findings being used in several European Commission and Parliamentary consultative and working papers. Patient Mobility in the European Union: Study on Legislative Proposals on Patients' Rights in Cross-Border Health Care (2008)^5.1 uses McKee's findings on the slow emergence of patient mobility on the European health policy agenda, on controversial court rulings, and his work for the European Observatory. A Commission staff working document accompanying the Directive proposal (2008) uses his findings on cross-border care in Slovenia, Austria and Italy.^5.2 A consultation paper from the EU Commission, published in 2006 but directly relevant to the eventual shape of the 2011 Directive, quotes McKee's findings on problems in cross-border health care due to incompatible rules between the countries concerned.^5.3 The quotes below amplify these uses.

The importance of McKee's work for the European Commission was underlined by Nick Fahy, former head of the Unit for Health Information at the Commission and former Deputy Head of the unit responsible for health systems and cross-border health care. In 2013 he commented that McKee's work had `been particularly influential ... His analysis has helped to shape the debate on issues such as cross-border health care and the emerging debate on a European health care policy ... and has been a reference point during legislative processes including the adoption of directive 2011/24/EU'. <sup>5.4</sup> Bernard Merkel, former head of the Commission's health strategy and health systems unit, responsible for the proposals for the Directive, added that McKee's work had made an `invaluable contribution' to providing answers to complex questions: `It was regarded by policy-makers as an authoritative source and thus had a significant influence both on the Commission's proposals as they evolved and on the political process of consideration by the European Parliament and the EU member states.'<sup>5.5</sup> Isabel de la Mata, Principal Advisor to the Directorate-General for Health and Consumers of the European Commission, stated that, `This work has been very important and influential to help us to develop the initial proposal for a Directive ... LSHTM work has always been a basic tool to support our actions.'^5.6 Throughout the impact assessment period, McKee held meetings with European Commission staff every six months and maintained fortnightly contact.

Between 2008 and July 2013, McKee advised individual governments on cross-border patient mobility, including those of Slovenia, Belgium, Sweden, the Netherlands, Spain, Ireland and Austria — in most cases at regular intervals. Regional governments in Italy also sought his advice — and a former EU health policy advisor for the Veneto Regional Government, Ilaria Passarani, praised the fact that, `he successfully reached the very difficult goal of bridging the gap between research and policy'.^5.7 In the UK, McKee's work was used by stakeholders preparing submissions to the consultation on the adoption of the Directive, including for the Scottish government (2008)^5.8 and the Northern Ireland Assembly.

At UK and international level, McKee also communicated his findings to health care stakeholders. In January 2009, he gave a presentation at the Royal College of Physicians (RCP) to an audience of RCP experts, government representatives and UK and EU stakeholder organisations. A similar audience was reached by his editorial in the BMJ (co-authored with Paul Belcher of the RCP) in July 2008.^5.9 Belcher, in his role as senior EU advisor to the RCP and board member of the European Public Health Alliance, commented that McKee's work had proved `invaluable ... Without this evidence base, our ability to influence political developments in Brussels would have been greatly weakened'.^5.10

McKee and Legido-Quigley advised the General Medical Council on patient mobility and the Directive throughout the impact assessment period, feeding into the Council's thinking on ways to respond to concerns about the mobility of medical professionals. At international level, McKee advised the European Union of Medical Specialists, a professional organisation of EU doctors. For the European Health Forum based in Gastein, Austria, McKee presented insights into the effects of the economic crisis on European health policy in May 2013.

EU countries have until 25 October 2013 to implement the Directive. Its full health benefits for the EU's citizens are just around the corner.

Sources to corroborate the impact

5.1 European Parliament Policy Department: Economic and Scientific Policy (2008) Patient Mobility in the European Union: Study on Legislative Proposals on Patients' Rights in Cross-Border Health Care, IP/A/ENVI/ST/2008-16, PE 408.577, requested by the Committee on the Environment, Public Health and Food Safety, European Parliament. Brussels, Belgium, http://www.europarl.europa.eu/document/activities/cont/201107/20110718ATT24286/20110718ATT24286EN.pdf (accessed 30 September 2013).

5.2 Commission of the European Communities (2008) Commission Staff Working Document: Accompanying Document to the proposal for a Directive of the European Parliament and of the Council on the Application of Patients' Rights in Cross-border Healthcare: Impact Assessment, COM(2008)414 final, SEC(2008)2164. Brussels: Commission of the European Communities, Brussels, Belgium,
http://ec.europa.eu/health/archive/ph_overview/co_operation/healthcare/docs/impact_assessment_en.pdf (accessed 30 September 2013).

5.3 Commission of the European Communities (2006) Communication from the Commission: Consultation Regarding Community Action on Health Services, SEC (2006) 1195/4 Brussels: Commission of the European Communities,
http://ec.europa.eu/health/ph_overview/co_operation/mobility/docs/comm_health_services_comm 2006_en.pdf (accessed 30 September 2013).

5.4-5.6 European Commission.

5.7 Veneto Regional Government, Italy.

5.8 Centre for International Public Health Policy (CIHP) (2008) Response to the Scottish Government's Consultation on the European Commission's Proposals for a Directive on the Application of Patients' rights in Cross-border Healthcare. Edinburgh:
CIHP,http://www.scotland.gov.uk/Resource/Doc/256823/0076235.pdf (accessed 30 September 2013).

5.9 McKee, M and Belcher, P (2008) Cross border health care in Europe, BMJ, 337(7662): 124-125, doi: 10.1136/bmj.39398.456493.80 (editorial).

5.10 Royal College of Physicians.