Select Committee on European Union Written Evidence

Memorandum by GJW Government Relations Ltd, Health Affairs


One of the aspects of European e-commerce policy that has received limited attention is how to deliver co-ordinated health policy using new media techniques. Some parts of this agenda are overtly e-commercial (such as Internet pharmacies), while others are less so (such as the National Electronic Library for Health). However, the online market for self-care medicinal products is expanding with about one in three e-consumers buying healthcare products online.[82] "e-health" is one facet of the expansion in e-commerce that needs to be addressed by the European Commission and European Member States in a significantly more informed and co-ordinated way.

  There are three aspects of e-health that the Committee may wish to consider:

    —  The quality, accuracy, security and identification of providers of health information via the Internet.

    —  Issues of Direct-to-Consumer advertising, independence of medical advice, the desirability of supplying Over-the-Counter and prescription drugs via the Internet.

    —  The role of NHS and independent providers in "e-health" policy.

  At present, neither the European Commission nor the United Kingdom Government has proposed sufficient measures to encourage e-health while also attending to the significant regulatory issues. This submission briefly addresses both sides of this current debate and offers policy proposals for the Sub-Committee to consider. The four most important are:

    —  e-Commercial sites may well lead to the provision of e-health capability. While initiatives like the e-Europe programme seek to bring Member States' health provision up to the speed, the nature of the Internet means that e-commerce models will drive the agenda. Member States will need to work in partnership with these businesses to maximise the advantages of e-health both across Europe and in the UK.

    —  A series of online kitemarks to act as guarantees for the quality, providence, and accuracy of the medical information supplied. While the European Commission should work with the nascent industry to facilitate these kitemarks, self-regulation should be the preferred model for the future of e-health.

    —  Greater emphasis should be given by the European Commission to the advantages of the Internet to deliver social policy online both efficiently and cost-effectively. The Commission is well placed to act as "cheerleader" for e-health and e-social policy, providing leadership and collective experience to all Member States.

    —  To promote the educational power of the Internet to inform patients and their carers. As Member States try to contain healthcare costs and the paternalist model of "doctor-knows-best" is eroded, patients want to learn about their condition, its treatments, and preventative measures. The underlying philosophy of e-health is to empower the individual to look after his/her own health most effectively.


  Put simply, e-health is a wide-ranging area of social policy that uses new media technologies to deliver both new and existing health outcomes. In the UK, it incorporates everything from NHS Direct online to Internet pharmacies to webcast operations involving consultants in another country. Across Europe and the United States, studies show that health-related websites are receiving more hits than even pornography sites.[83] At the moment, the main focus of e-health is on patient empowerment and self-care. As the area develops, e-health could expand to include online long-term disease management, personalised health checks, and more efficient primary care services due to informed patients accessing the healthcare system at the most appropriate point.

Advantages of currently available e-health services include:

  More efficient and cost-effective means of delivering health services. For example, trials are ongoing in the Midlands with GP appointment systems that e-mail the patients with convenient times and proactively send repeat prescription reminders.

  Easy and convenient access for patients and their carers to high quality medical information. NHS Direct online receives about 100,000 hits each month. The NHS brand offers a quality guarantee on the information available. In the same way that the nurses operating the NHS Direct phone line can offer self-care advice, so the online service will soon include self-care advice. Information will be available on Over-the-Counter medicines, medication, and symptoms.

  More flexible access to sources of self-care online. The numbers of community pharmacies are dwindling owing to the twin effects of out-of-town supermarkets replacing high street community pharmacies, and large pharmacy chains locating only in areas of high footfall. Online pharmacies such as "Pharmacy2U" and "Allcures" will soon offer door-to-door nationwide delivery at lower cost to the patient.

Disadvantages of e-health include

  Lack of face-to-face contact between health professional and patient. This lack of contact can lead to confusion, unnecessary worry, and even misdiagnosis (although misdiagnosis usually stems from erroneous self-diagnosis based on incorrect information contained on health advice websites).

  Concerns over the security of patient information. Both the UK Government and the European Commission have outlined plans for a form of Electronic Patient Record in order to deliver the most appropriate care by the most appropriate health professional in the most appropriate setting. However, concerns about the security of patient information have delayed these plans.

  The considerable difficulty of enforcing the current UK and EU regulatory regimes across the international Internet. These regulatory regimes include a ban on Direct-to-Consumer advertising, numerous specifications on the quality of the medical advice given, and differences in legal opinion over the safe delivery of medicines.


  The draft Action Plan e-Europe: An Information Society for All is a useful summary of the Commission's vision for e-health development across Member States. The Lisbon conference in March 2000 highlighted the difficulties of delivering this e-health agenda.

  Information Society for All stresses that "the efficient provision of quality health services to all citizens in the future is one of the most difficult challenges facing all European governments." The document goes on to note that "secure [information technology] services have to be developed linking hospitals, laboratories, pharmacies, primary care centres and homes of people." The paper concludes that "the Union has every incentive to co-operate in the protection and improvement of public health (Article 152 of the Treaty). This does not mean harmonising health care at European level. However, it does mean working together by conducting research, agreeing standards and produce specifications and building pan-European medical libraries."

  The Lisbon conference agreed a number of targets for European e-health. They are:

  By the end of 2000: Best practices of healthcare regional networks should be identified and priorities for medical libraries-online set. Health care informatics standardisation priorities to be implemented by end 2000.

    —  The development of online medical libraries, next generation smartcards for healthcare and more user-friendly infrastructures are included in the Work Programme for the Information Society Technology programme 2000. However, this work programme is already out of date. There are a number of online health libraries already in existence, ranging from academic libraries to self-care advice. At one end of this spectrum is the Organising Medical Networked (OMNI) system of kitemarked biomedical information through to Discern Online targeted at consumers. Both these sites are linked to NHS Direct online website. However, a superior online medicines and healthcare compendium will be launched in May 2000 that could render these libraries redundant. Will the Commission have the resources, the political will, or the knowledge to keep up (let alone lead) this development?

    —  The Commission proposes to encourage take-up of health information networks at Member State and trans-national level. How will this encouragement take shape? Is the Commission considering a comprehensive public education programme about e-health? In the United States, the Food and Drugs Agency (FDA) has begun a national campaign to warn consumers of the dangers of buying medicines online. In part this campaign is to counteract the massive advertising effort of online health companies such as Healtheon and Dr Koop. These market leaders created an environment where there are now approximately 400 online pharmacies in the US. One option would be for the Commission to work with these start-up companies to develop self-regulatory models as the market emerges rather than trying to alter the market once it is established.

    —  The Commission also proposes that Member States should implement secure and efficient health telematics systems and services based on standards as adopted by European Standards Body (CEN). How will the Commission build a European consensus on the wider issues of the implementation of health telematics systems and services such as confidentiality of health data, quality of service and liability of service providers (including authenticity of pharmaceutical supply and medical advice)?

  By the end of 2003: Implementation of informatics tools (health cards, health information and education networks) to facilitate citizens' active involvement in prevention and treatment of diseases.

    —  The technology already exists to mass-produce health smartcards. Indeed, every British citizen already has an NHS number. However, the political will to introduce the mandatory smartcards is much weaker in the UK than it is on the Continent where many citizens already carry the equivalent documentation. While it is more logical for the Commission to drive this measure, the Member State will provide the political will to ensure national comprehensive systems. It will be difficult for the Commission to co-ordinate this programme.

    —  Although the UK Government is taking the lead in facilitating patient information and advice online through the NHS Direct service, it is the entrepreneurial health websites and portals that are currently leading the effort to deliver citizens' active involvement in prevention and treatment of diseases. UK examples include Pharmacy2U, NetDoctor, and Allcures. Citizen involvement here suffers from a lack of regulatory standards about the health information on offer. Following the example of online financial services, a series of kitemarks could act as guarantees for the quality, providence, and accuracy of the medical information supplied. While the European Commission should work with the nascent industry to facilitate these kitemarks, self-regulation should be the preferred model for the future of e-health.

  By the end of 2004: Health professionals and managers to be linked to an electronic health infrastructure.

    —  The trials and tribulations of NHSNet provide the template for introducing an electronic infrastructure across Europe. The British Medical Association convincingly diverted Department of Health plans on the shape of this service; pharmacists were effectively excluded on cost grounds; nurses are at a clear disadvantage due to a lack of access and training. This provides the context for the NHS Information Strategy that centres on Electronic Patient Records (possibly contained on smartcards) by 2005. Without these EPRs, a modernised 24-hours healthcare service will not be able to function due to lack of information about the patient.

    —  Greater emphasis should be given by the European Commission to the advantages of the Internet to deliver social policy online both efficiently and cost-effectively. The Commission must not view e-health as about electronic data interchange between health professionals but as a much wider tool of social policy. The Commission is well placed to act as "cheerleader" for e-health and e-social policy, providing leadership and collective experience to all Member States. However, the Commission will be aware that electronic health infrastructures will develop at different speeds both within and between Member States. Is the Commission concerned that UK healthcare companies will seek new markets in Europe and enter these markets by offering cut price IT systems both to health professionals and to patients? The implications of this US expansion range from importing US health models like Health Management Organisations (HMOs) to challenge the tax base upon which mixed healthcare markets operate across Europe. The UK's NHS will be particularly affected by HMOs restructuring primary care arrangements.

    —  It is interesting to compare the Commission's aspirations on "e-education" and "e-health". Whereas the former looks to all pupils being digitally literate by the time they leave school, the latter looks only to professionals rather than patients to have the equivalent health digital literacy. The educational power of the Internet to inform patients and their carers needs to be promoted. As Member States try to contain healthcare cost and the paternalist model of "doctor-knows-best" is eroded, patients want to learn about their condition, its treatments, and preventative measures.[84] The underlying philosophy of e-health is to empower the individual to look after his/her own health most effectively.


  Regulators of the global Internet pharmacy market appear to be converging towards a common approach. Democrat Members of the House of Representatives are leading the Clinton Administration efforts to put Internet pharmacies under the supervision of the Food and Drug Agency from October 2000. This "crack down" has been sufficient to cause market predictions to be cut back. Researchers now estimate that the American Internet pharmacy markets will be worth $10 billion by 2004.[85] The European Commission, on the other hand, is moving to deregulate e-commerce and e-health in the hope of kick-starting growth in an inactive market.

  However, the Internet is renown for rewriting existing rule books on working practices and revenue streams. This will be seen with a succession of partnerships between pharmaceutical or communications companies and health care providers to develop computer-based decision support systems. These new technologies will be used in surgeries, pharmacies, shopping centres, and high streets to provide patient information on medical treatments. Certainly, this fits in well with UK Ministers' stated intentions on NHS Direct Online and Walk-In Centres.

  Some form of active self-regulation by e-health providers within a framework of European Commission standards may be the best way forward. The established methods of self-regulation can protect vested professional interests. This may push consumer-orientated patients to more open, accessible services where the standards are not so vigorous. Yet legislative regulation can never keep pace with rapid Internet innovations and officials are rightly reluctant to try. Instead, could the Commission take the lead in persuading individual e-customers to accept a responsibility to seek the best professional advice even if it means greater effort and expense on the customer's behalf?


  There is an overwhelming need to establish which DG is leading on e-health. At the moment, it is split between DG XXIV (Consumer Health Protection), DG XIII (Information Society), and DG III (Consumer Affairs). The result, predictably, is a lack of clear priority setting. This can be seen in the lack of response to regulatory issues for e-health. In January 2000, the European Parliament published a draft report on ways of regulating the marketing and sale of prescription pharmaceuticals on the Internet. The report—by the Parliament's Scientific and Technology Options Assessment (STOA) Unit—recognised that e-commerce will affect the pharmacy sector and states that the European Parliament should take the lead in legislating for a regulatory framework.

  This report proposed two useful policy options:

    —  Modification of current EU legislation on advertisement of and commerce in medicines by explicitly considering the particularities of the electronic media and services.

    —  To push the pharmaceutical industry to establish agreements on "Good-Internet-marketing-practice". This code of practice would serve as a self-control instrument for the pharmaceutical industry in order to safeguard consumers' interests.

  The number of e-commerce initiatives, proposals, and draft directives that touch on this area can gauge the impact of e-health. Affected areas include: the draft Electronic Commerce Directive, the Data Protection Directive, the Copyright Directive, the Brussels Convention, Online dispute resolution, Internet governance, the Electronic Signatures Directive, Internet and broadcasting, Trademarks, and the Electronic Communications Review. Almost every Directorate-Generale is affected by at least one of these issues. Without co-ordination, e-health may at best develop as an unregulated patchwork of online services across Europe, confusing the patient and frustrating Commission efforts to deliver improved health outcomes online. At worst, across Europe "e-health" could become a byword for unpredictable quality, unprofessional medical advice, and patients' health outcomes becoming prey to unscrupulous profiteers.

29th March 2000

82   Forester Research, May 1999. Back

83   Datamonitor, November 1999. Back

84   Cyber Dialogue (December 1999) reported that one-third of American chronic disease sufferers who seek disease information online report taking their medications more regularly following a visit to a disease-specific website. Back

85   Jupiter Communications (January 2000). Back

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