Healthcare across EU borders: a safe framework - European Union Committee Contents

CHAPTER 5: Communication, provision of information and language considerations

The issue

94.  In this chapter we consider the provision of information in cross-border healthcare—what this information should comprise, where responsibility rests for ensuring its availability and what issues might need to be addressed in its provision. We also explore how the issue of language variation across the Member States should be addressed in the cross-border healthcare context.

Contents of the proposal

95.  Under the Directive, the home Member State shall ensure that there are mechanisms in place to provide patients on request with information on receiving healthcare in other Member States, and the terms and conditions that would apply, for example, when harm is caused as a result of healthcare received in another Member State. This information should be made easily accessible, including by electronic means, and shall include information on patients' entitlements, on procedures for taking up those entitlements and on systems of appeal and redress. Article 10, which sets down these requirements, also states that the Commission may develop a standard Community format for this information.[36]

96.  The Directive also proposes the establishment of national contact points to address information requirements. The form and number of the national contact points is to be decided by individual Member States.[37] Within the home Member State, the national contact point should provide and disseminate information to patients on their rights to cross-border healthcare and the processes involved in exercising those rights. They should also help patients to protect their rights and to seek redress where necessary.[38]

Information: why it is needed and what it should cover

97.  There was a general recognition of the need for provision of information on cross-border healthcare. (QQ 28, 118, 253, pp 53, 54, 91, 92, 168) In particular, information was required to enable patients to make an informed decision about whether to use cross-border care. PA Consulting highlighted that "people would make a choice on a small number of factors" and that, in the absence of real information, patients might make a choice that they would later regret. (Q 28) The Patient Liaison Group of the Royal College of Surgeons highlighted a current lack of knowledge about using cross-border healthcare and suggested that it "will only be an advantage if patients are given enough information on which to base their decision to seek treatment from another state." (p 53, 54)

98.  The Royal College of Nursing (RCN) highlighted the need for information for healthcare professionals as well as for patients; this was not explicitly addressed in the proposal. Given the role of health professionals in advising patients and assisting in the interpretation of healthcare information, the RCN stated that it was important that this need was addressed. (Q 259, p 92)

99.  There was a broad consensus that information provided to potential cross-border patients should include details about the processes involved (that is, how to navigate the system), eligibility, and likely costs and level of reimbursement. (Q 198, pp 17, 70-71, 92, 119, 159) This information should be easily accessible and understandable. (QQ 118, 133, pp 90, 92)

100.  Several groups supported the provision of information on redress and complaints. (QQ 134-135, 201, pp 43, 70-71, 74, 119, 167-168) The British Medical Association (BMA) stressed that such information should also include details about the culture of care as this will differ considerably across Member States, on points such as whether the patient is expected to have family members present to offer some of the care. The BMA stated that "Those things are of absolute key importance but they are not something that you would have to put in a document for British nationals knowing about British healthcare but you do need to when you are looking at other countries." (Q 296)

101.  The Minister thought that the standard Community format, that the Commission may develop for information to be provided to patients, might only work for the basic and common details shared by Member States. She highlighted the variation between Member States' healthcare systems and suggested that to try to capture all details on one form could prove to be difficult and unusable for patients. (p 30)

Information: responsibility for provision

102.  There were differing views among witnesses as to where responsibility for provision of information should rest, and some were unsure; but we found little support for the proposals in the draft Directive. The British Dental Association, the Medical Defence Union and the General Medical Council all suggested that it should be for the Member State of treatment to provide information about its own healthcare. (QQ 116-119, 200, pp 73, 115) On the other hand, the Patient Liaison Group of the Royal College of Surgeons and the British Medical Association highlighted the potential for an EU-level responsibility in this area. (Q 147, p 119) This view was supported by the NHS Confederation's assertion that it would be unreasonable to expect clinicians and local commissioners to give detailed advice on how other Member States' systems operate. (QQ 254-255, p 90)

103.  The Royal College of Nursing outlined a more collective form of responsibility within individual Member States involving three levels: practitioners; providers and commissioners; and Member States. They also suggested that "there would have to be some very comprehensive communication and training and development for people on the frontline … Nurses in that situation would need some very clear guidance about the extent of their role as advocates of choice without making too many very clear recommendations and pushing people one way or the other." (Q 256) This concern was echoed by the Medical Protection Society in relation to general practitioners: "we think it is of absolute crucial importance that they should not be held liable for the quality of the information that should be available at a national level." (Q 136)

Information: national contact points

104.  Linked to the issue of responsibility for information provision is the proposed system of national contact points, which were largely supported by our witnesses. (pp 55, 90, 92, 105, 116, 119) Nevertheless, none of those we spoke to had a view on the exact nature of these national contact points, nor on where responsibility for their organisation, funding and delivery of information should rest. (QQ 133, 145, 147, 198-199, 200, 253-256, 295-296, 339-341)

105.  The British Dental Association (BDA) and the NHS Confederation qualified their support. The BDA suggested that in the light of thirty years of freedom of movement of professionals it would be difficult to achieve the sharing of information between Member States, and the NHS Confederation highlighted that the national contact points could not give personal advice on the best care or act as advocates for individual patients. (pp 90, 105, 116) The latter point was also taken up by the Nursing and Midwifery Council which drew a distinction between types of information: national contact points could cover patients' rights, but information on treatment had to come from medical professionals. (Q 198)

106.  UNISON highlighted national contact points as one of a number of measures that would place an additional administrative burden on the health systems of Member States. (p 134) In contrast, the British Medical Association welcomed the introduction of national contact points and stated that it was "pleased that this added administrative burden [of providing information] will not fall on medical professionals." (p 119)

107.  The Commissioner explained that it would be for each Member State to decide how to organise their national contact point(s), including their number and location, with the flexibility to have regional contact points. She indicated that the Commission would have a role in helping with the management of the network of national contact points and agreed that the information provided across this network should be consistent. (QQ 381-382)

Information: issues to address

108.  The General Medical Council, the Association of British Insurers and the NHS Confederation all stressed that no new costly, administrative burdens should be imposed on Member States or bodies within them through the information provision requirements. (pp 73, 90, 158) Moreover, the Minister and the NHS Confederation questioned how much practical information Member States would be able to provide about healthcare abroad. (Q 71, p 104) The NHS Confederation and the PLG suggested that vulnerable patients and those from lower socio-economic groups might require extra help or support in making the decision about whether to use cross-border healthcare. (pp 53, 105)

109.  Several witnesses addressed the issue of the promotion of cross-border healthcare. The Minister stated that there was no obligation for Member States to promote cross-border healthcare and that the Government would not do so, though they would not attempt to keep information from patients about their rights. (QQ 69-70) The NHS Confederation also believed that the promotion of cross-border healthcare should not be an objective in itself. (p 88) However, the PLG suggested that awareness of cross-border healthcare could be increased through a national advertising campaign. Without such activity, the PLG stated that "There will be inequity, because those who are on the ball, who are on the internet, who find out these things, will go ahead and find out and they will make the best decision. Those who do not have that available will not know that that option is available and will not know how to make the choice." (QQ 149-150)

Language considerations

110.  The variation in language across the Member States was highlighted as a potential barrier to the delivery of cross-border healthcare. (QQ 25, 79, 153-154, 168-169, 198, 220, 224, pp 54-55, 115, 118, 160) Two main areas were emphasised: the sharing of medical notes and patients' medical records across Member States and the need for patients to give informed consent for treatment.

111.  The British Medical Association (BMA) suggested that "Continuity of care should be ensured by a unified system of handover between clinicians as language problems and different decision making procedures may impact on patient safety." (p 118) This point was echoed by the Association of British Insurers and the Royal Pharmaceutical Society, who stated that "If a patient is treated in, say, Poland, you want to be able to have the notes brought back to this country and understood by whoever is providing continuing care—which is often quite difficult." (Q 168, p 160)

112.  The BMA suggested that medical records should be kept in the language of the patient's country of origin, highlighting the potential need for translation provision in Member States. (p 119) The Patient Liaison Group of the Royal College of Surgeons (PLG) was concerned as to whose responsibility it would be to ensure that patient notes and data are not misinterpreted. (p 55)

113.  The British Dental Association (BDA), the Nursing and Midwifery Council and the General Medical Council focused on the need for a patient to understand the information being conveyed to them by the healthcare provider in another Member State in order to provide informed consent, a right which could not be waived by the patient. (QQ 198, 220, 224, p 115)

114.  There were different views about who should be responsible for addressing the language barrier in cross-border healthcare. The Minister and the PLG both suggested that responsibility should rest with the individual. (QQ 79, 153, p 17) The Commissioner stated that responsibility should not rest with the host Member State and that where they had to pay for interpretation facilities they should charge for this service, leaving the home Member State or the patient with ultimate responsibility for the costs incurred. (Q 392) Similarly, the BMA believed that it would be unfair to burden the host Member State with the responsibility of language provision and suggested that further work was needed on this in the proposal. (p 118) By contrast, PA Consulting suggested that the host Member State should be responsible for the additional costs arising out of the language barrier, particularly in order to collate clinical information and obtain consent for procedures. In arguing their view, PA Consulting made the same suggestion as the Commissioner, whereby the host State would be entitled to incorporate the extra costs in its charge for healthcare services. (p 4)

Conclusions and recommendations

115.  We believe that the provision of accessible and comprehensive information to patients and medical practitioners is key to the success of the Directive. Patients will only be able to make an informed decision on whether to seek cross-border treatment if they have access to relevant information. Similarly, practitioners will need access to this information in order to advise patients appropriately. We consider that the provision and financing of information must be the responsibility of the home Member State.

116.  The Commission proposes that the information provided should include details about receiving healthcare in another Member State, the terms and conditions that would apply, patients' entitlements, procedures for using those entitlements and systems of appeal and redress if the patient is deprived of such entitlements or harm is caused as a result of healthcare received in another Member State. We agree with the Commission's suggestions about what information for patients should include. However, we recommend that a standard Community format for the provision of this information should not be drawn up. The different procedures and processes that would need to be taken into account are numerous and we believe that this could result in the information being presented in a format that is difficult for patients to understand or use.

117.  We consider that there is a lack of clarity in the Directive as to who is responsible for providing information on the service available in a particular Member State. We recommend that the government of each Member State should be responsible for describing their own health system. Furthermore, we consider that the exact role of national contact points in the provision and dissemination of information, and where responsibility for them should rest, should be clarified in the Directive.

118.  The current lack of clarity over who is to provide what information, and how, creates the potential for this burden to fall primarily on medical practitioners. While their involvement may be beneficial for helping patients make an informed decision about cross-border care (see paragraph 72), we recommend that the Directive makes clear that front line health providers giving this information to patients should be protected against complaints made against them if a patient suffers unexpected harm in the course of subsequent treatment abroad.

119.   Furthermore, we fear that the need to provide information and advice on cross-border treatment would interfere with the performance of practitioners' duties and could detract from the standard or timeliness of treatment of local patients. We therefore recommend that the Directive should avoid the imposition of any administrative burden on healthcare practitioners due primarily to information provision obligations.

120.  It is clear that language may prove to be a barrier in the delivery of cross-border healthcare and that this may impact on a patient's choice to travel. We therefore consider that patients must be made aware of any language issues and costs before they seek cross-border healthcare. Language barriers could prove particularly critical in the areas of giving consent and ensuring continuity of care and patient safety. We recommend that the responsibility for addressing the language barrier is decided by the home Member State.

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36   (COM (2008) 414) Article 10(1), (2) & (3) Back

37   (COM (2008) 414) recital 36 Back

38   (COM (2008) 414) Article 12 Back